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The nurse should do which of the following to decrease a female client's anxiety about being placed in the lithotomy position for surgery?
- A. Explain in detail what will occur in the operating room.
- B. Determine what the client is concerned about.
- C. Pad the stirrups for comfort.
- D. Reassure the client that an all-female surgical team will be present.
Correct Answer: B
Rationale: Determining the client's specific concerns about the lithotomy position allows the nurse to address her anxiety directly, promoting trust and tailored reassurance.
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A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order should the nurse teach the client to perform diaphragmatic breathing and coughing?
- A. Inhale through the nose.
- B. Cough deeply from the lungs.
- C. Exhale through pursed lips.
- D. Splint the incisional site.
Correct Answer: D,A,C,B
Rationale: The correct order is: splint the incision (D) to reduce pain, inhale through the nose (A) to expand lungs, exhale through pursed lips (C) to control breathing, and cough deeply (B) to clear secretions.
The nurse is preparing a continuing education course on blood transfusion reactions. The nurse recognizes which intervention would prevent an ABO incompatibility (hemolytic) transfusion error.
- A. Priming a Y-tubing blood administration set with 0.9% sodium chloride (normal saline).
- B. Ensure that the client has a patent 20-gauge peripheral vascular access device.
- C. Accurately label the client's blood specimen for crossmatching.
- D. Review the client's medication allergies.
Correct Answer: C
Rationale: Accurate labeling of the client’s blood specimen for crossmatching ensures the correct blood type is matched, preventing ABO incompatibility reactions. Priming with saline, ensuring IV access, and reviewing allergies do not directly prevent ABO mismatches.
The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
- A. Obtain adequate bed rest.
- B. Increase fluid intake.
- C. Follow a high-protein diet.
- D. Avoid carbohydrates.
Correct Answer: A
Rationale: Adequate bed rest (A) supports recovery in viral hepatitis by reducing metabolic demands. Increased fluids (B) are helpful but secondary. High-protein (C) or avoiding carbohydrates (D) is not indicated.
The nurse should plan to begin rehabilitation efforts for the burn client:
- A. Immediately after the burn has occurred.
- B. After the client's circulatory status has been stabilized.
- C. After the client's pain has been eliminated.
- D. After the client's pain has been eliminated.
Correct Answer: B
Rationale: Rehabilitation begins after stabilizing the client's circulatory status (emergent phase), as this ensures survival and allows focus on recovery. Immediate rehab is unsafe, and complete pain elimination is unrealistic.
Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)?
- A. Increased anteroposterior chest diameter.
- B. Underdeveloped neck muscles.
- C. Collapsed neck veins.
- D. Increased chest excursions with respiration.
Correct Answer: A
Rationale: Advanced COPD causes air trapping, increasing anteroposterior chest diameter (barrel chest). Neck muscles may hypertrophy from respiratory effort. Neck veins may distend, and chest excursions decrease due to lung hyperinflation.