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When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote
- A. Relaxation and sleep
- B. Deep breathing and coughing
- C. Incisional healing
- D. Range of motion exercises
Correct Answer: B
Rationale: Effective pain management encourages deep breathing and coughing, which are crucial for preventing complications after thoracic surgery. These actions help prevent respiratory complications such as pneumonia and atelectasis, promote lung expansion, and improve oxygenation. While relaxation and sleep are important for recovery, the priority after a thoracotomy and lobectomy is to prevent respiratory issues. Incisional healing is important but not the primary focus immediately post-surgery. Range of motion exercises are not directly related to promoting recovery after thoracic surgery.
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A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?
- A. Increased blood pressure
- B. Increased heart rate
- C. Loss of pulse in the extremity
- D. Decreased urine output
Correct Answer: C
Rationale: Loss of pulse in the extremity can indicate an arterial blockage, requiring immediate medical evaluation. Increased blood pressure and heart rate are common physiological responses after cardiac catheterization and may not necessarily indicate a complication. Decreased urine output is more indicative of renal function and may not be directly related to complications from the procedure.
A client with a history of deep vein thrombosis (DVT) is being treated with anticoagulants. Which of these findings is most concerning to the nurse?
- A. Presence of bruising on the arms and legs
- B. The client reports new onset of severe headache
- C. The client reports pain and swelling in the calf
- D. The client reports increased urination
Correct Answer: C
Rationale: The correct answer is C because pain and swelling in the calf can indicate a new or worsening DVT, requiring immediate attention. Bruising on the arms and legs may be a common side effect of anticoagulants but is not as concerning as a potential DVT. Severe headache may indicate other conditions like a migraine or hypertension and is not directly related to DVT. Increased urination is not typically associated with DVT and may point towards other health issues like diabetes or urinary tract infections.
Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?
- A. Sensory perceptual alterations related to decreased vision
- B. Alteration in mobility related to fatigue
- C. Impaired gas exchange related to retained secretions
- D. Altered patterns of urinary elimination related to nocturia
Correct Answer: D
Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.
A client wants to increase her daily intake of omega-3 fatty acids. Which of the following foods should the nurse suggest the client increase?
- A. Blueberries
- B. Soybean oil
- C. Citrus fruits
- D. Green tea
Correct Answer: B
Rationale: The correct answer is B: Soybean oil. Soybean oil is a good source of omega-3 fatty acids, which are beneficial for heart health. Blueberries (choice A), citrus fruits (choice C), and green tea (choice D) are not significant sources of omega-3 fatty acids. Blueberries are rich in antioxidants, citrus fruits provide vitamin C, and green tea contains polyphenols, but they do not offer a substantial amount of omega-3 fatty acids compared to soybean oil.
A nurse is reinforcing teaching with a client who has COPD. Which of the following instructions by the nurse is appropriate?
- A. Drink carbonated beverages.
- B. Decrease fiber intake.
- C. Use bronchodilators after meals.
- D. Increase protein intake.
Correct Answer: D
Rationale: The correct answer is to instruct the client to increase protein intake. This is appropriate because increasing protein intake can help maintain muscle mass and strength in clients with COPD. Option A, 'Drink carbonated beverages,' is incorrect as carbonated beverages can exacerbate COPD symptoms. Option B, 'Decrease fiber intake,' is also incorrect as fiber is important for digestion and should not be decreased unless specifically advised by a healthcare provider. Option C, 'Use bronchodilators after meals,' is incorrect because bronchodilators are typically used before meals to help open the airways for better breathing, not after meals.