Nokea
When performing postural drainage, which of the following factors promotes the movement of secretions from the lower to the upper respiratory tract?
- A. Friction between the cilia.
- B. E. Force of gravity.
- C. Sweeping motion of cilia.
- D. Involuntary muscle contractions.
Correct Answer: B
Rationale: The force of gravity in postural drainage positions the body to allow secretions to drain from lower to upper airways. Cilia and muscle contractions aid clearance but are not the primary mechanism.
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A client has acute arterial occlusion. The physician has ordered a thrombolytic agent. Before starting the medication, the nurse should:
- A. Review the blood coagulation laboratory values
- B. Test the client's stools for occult blood
- C. Count the client's apical pulse for 1 minute
- D. Check the 24-hour urine output record
Correct Answer: A
Rationale: Before administering a thrombolytic agent for acute arterial occlusion, the nurse must review coagulation lab values (e.g., aPTT, INR, platelets) to assess bleeding risk, as thrombolytics increase hemorrhage potential. Stool testing, pulse counting, and urine output are secondary or unrelated.
A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation?
- A. Tell the client firmly that she needs assistance and help her with her care.
- B. Praise the client for her desire to be independent and give her extra time and encouragement.
- C. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help.
- D. Suggest to the client that if she insists on self-care, she should at least modify her routine.
Correct Answer: B
Rationale: Praising independence and providing extra time respects the client's autonomy while supporting her efforts. Forcing help, labeling her unrealistic, or suggesting modifications may undermine her dignity.
The nurse should teach the client with an ileal conduit to prevent urine leakage when changing the appliance by using which of the following procedures?
- A. Insert a gauze wick into the stoma.
- B. Close the opening temporarily with a cellophane seal.
- C. Suction the stoma before changing the appliance.
- D. Avoid oral fluids for several hours before changing the appliance.
Correct Answer: A
Rationale: Inserting a gauze wick into the stoma temporarily absorbs urine, preventing leakage during appliance changes, ensuring a dry field for secure adhesion.
Which position would most help to decrease a client's discomfort when the client's spouse injects vitamin B12 using the ventrogluteal site?
- A. Lying on the side with legs extended.
- B. Lying on the abdomen with toes pointed inward.
- C. Leaning over the edge of a low table with hips flexed.
- D. Standing upright with the feet one shoulder-width apart.
Correct Answer: B
Rationale: The ventrogluteal site is best accessed when the client lies on their abdomen with toes pointed inward, as this position relaxes the gluteal muscles and minimizes discomfort during injection. The other positions do not optimally relax the muscle or provide access to the ventrogluteal site.
The client's serum potassium level is elevated in acute renal failure, and the nurse administers sodium polystyrene sulfonate (Kayexalate). This drug acts to:
- A. Increase potassium excretion from the colon.
- B. Release hydrogen ions for sodium ions.
- C. Increase calcium absorption in the colon.
- D. Exchange sodium for potassium ions in the colon.
Correct Answer: D
Rationale: Kayexalate exchanges sodium for potassium in the colon, reducing serum potassium levels in acute renal failure.