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When performing chest percussion on a child, which of the following techniques should the nurse use?
- A. Firmly but gently striking the chest wall to make a popping sound.
- B. Gently striking the chest wall to make a slapping sound.
- C. Percussing over an area from the umbilicus to the clavicle.
- D. Placing a blanket between the nurse's hand and the child's chest.
Correct Answer: A
Rationale: Chest percussion involves firmly but gently striking the chest to produce a popping sound, mobilizing secretions without causing harm.
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The nurse is teaching a client with a new tracheostomy about home care. Which of the following instructions should be included? Select all that apply.
- A. Clean the tracheostomy site daily.
- B. Suction the tracheostomy as needed.
- C. Change the tracheostomy tube monthly.
- D. Keep a spare tracheostomy tube at home.
- E. Use a humidifier to keep secretions thin.
Correct Answer: A, B, D, E
Rationale: Daily cleaning, suctioning, keeping a spare tube, and using a humidifier are essential for tracheostomy care. Tube changes are typically done by professionals.
The nurse is teaching a client about self-administration of insulin. Which site should the nurse recommend for fastest absorption?
- A. Abdomen
- B. Thigh
- C. Arm
- D. Buttock
Correct Answer: A
Rationale: The abdomen has the fastest insulin absorption rate due to its rich blood supply and minimal muscle interference.
The nurse is caring for a client with a history of osteoarthritis. Which of the following non-pharmacologic interventions should be included in the plan of care?
- A. Apply heat to affected joints.
- B. Restrict weight-bearing activities.
- C. Encourage a low-protein diet.
- D. Limit range-of-motion exercises.
Correct Answer: A
Rationale: Heat therapy reduces stiffness and pain in osteoarthritis.
After explaining to a multigravid client at 36 weeks' gestation who is diagnosed with severe hydramnios about the possible complications of this condition, which of the following statements indicates that the client needs further instruction?
- A. Because I have hydramnios, I may gain weight.'
- B. Hydramnios has been associated with gastrointestinal disorders in the fetus.'
- C. I should continue to eat high-fiber foods and avoid constipation.'
- D. I can continue to work at my job at the automobile factory until labor starts.'
Correct Answer: D
Rationale: Severe hydramnios increases risks like preterm labor, requiring activity restrictions; continuing physically demanding work indicates a need for further teaching.
A nurse performs care on the client's Hickman catheter according to hospital policy. The client develops an infection and is considering litigation. The nurse's practice is:
- A. Malpractice
- B. Hespondeat superior
- C. Negligent
- D. Tort
Correct Answer: B
Rationale: Respondeat superior is Latin for 'The master is responsible for the acts of his servant'. The nurse, as an employee of the hospital, acted according to the established policy of the hospital. Because the nurse followed hospital policy, it is unlikely that this incident involved malpractice, negligence, or tort law. (CN: Management of care; CL: Evaluate)