Nokea
When performing the Heimlich maneuver on a conscious adult victim, the rescuer delivers inward and upward thrusts specifically:
- A. Above the umbilicus.
- B. At the level of the xiphoid process.
- C. Over the victim's midabdominal area.
- D. Below the xiphoid process and above the umbilicus.
Correct Answer: D
Rationale: The Heimlich maneuver involves thrusts below the xiphoid process and above the umbilicus to safely dislodge a foreign body without injuring internal organs.
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A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is now 'unable to concentrate at her card game' and 'it seems harder and harder to finish her errands because of exhaustion.' Based on this information, the nurse should suggest that the client do which of the following?
- A. Take frequent naps.
- B. Limit activities.
- C. Increase fluid intake.
- D. Avoid contact with others.
Correct Answer: A
Rationale: The client's symptoms of difficulty concentrating and exhaustion suggest fatigue, which is a common long-term side effect of chemotherapy. Taking frequent naps can help manage fatigue by allowing the client to rest and conserve energy, improving her ability to perform daily activities. Limiting activities may be overly restrictive and not address the root issue, increasing fluid intake is not directly related to fatigue unless dehydration is present, and avoiding contact with others is unnecessary unless there is an infection risk.
The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected?
- A. Normal breath sounds.
- B. Prolonged inspiration.
- C. Normal chest movement.
- D. Coarse crackles and rhonchi.
Correct Answer: D
Rationale: COPD exacerbation with infection produces coarse crackles and rhonchi from secretions and airway inflammation. Breath sounds are diminished, expiration is prolonged, and chest movement is reduced.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
- A. Hyperalbuminemia.
- B. Thrombocytopenia.
- C. Hypokalemia.
- D. Hypercalcemia.
Correct Answer: C
Rationale: Crohn's disease with diarrhea can lead to hypokalemia due to potassium loss in stool. Hyperalbuminemia and hypercalcemia are not typical, and thrombocytopenia is less directly related to these symptoms. CN: Physiological adaptation; CL: Analyze
Which of the following health promotion activities would be appropriate for the nurse to suggest that the client with cirrhosis add to the daily routine at home?
- A. Supplement the diet with daily multivitamins.
- B. Limit daily alcohol intake.
- C. Take a sleeping pill at bedtime.
- D. Limit contact with other people whenever possible.
Correct Answer: A
Rationale: Multivitamins (A) address nutritional deficiencies common in cirrhosis. Alcohol (B) must be completely avoided, sleeping pills (C) risk encephalopathy, and social isolation (D) is unnecessary.
A nurse is caring for a client at home on hospice care for terminal renal cancer. People are calling the nurse to inquire about the client's condition. The nurse should tell the callers:
- A. Please call the oncologist.
- B. The client is in a coma now.
- C. Please call the client's sister.
- D. The client is not expected to live much longer.
Correct Answer: C
Rationale: Directing callers to the client's sister respects privacy and ensures consistent communication, aligning with the family's preferences in hospice care.