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When teaching a client to deep breathe effectively after a lobectomy, the nurse should instruct the client to do which of the following?
- A. Occurnt the abdominal muscles, take a slow deep breath through the nose and hold it for 3 to 5 seconds, then exhale.
- B. Contract the abdominal muscles, take a deep breath through the mouth, and exhale slowly as if trying to blow out a candle.
- C. Relax the abdominal muscles, take a slow deep breath through the nose, and hold it for 3 to 5 seconds.
- D. Relax the abdominal muscles, take a deep breath through the mouth, and exhale slowly over 10 seconds.
Correct Answer: C
Rationale: Effective deep breathing post-lobectomy involves relaxing abdominal muscles, taking a slow nasal breath, holding it 3–5 seconds, and exhaling to expand lungs. Contracting muscles or mouth breathing is less effective.
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A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:
- A. Institute range-of-motion (ROM) exercise every 4 hours.
- B. Massage the abdomen once a shift.
- C. Use an alternating air pressure mattress.
- D. Elevate the lower extremities.
Correct Answer: C
Rationale: An alternating air pressure mattress (C) prevents pressure ulcers in clients with edema and ascites. ROM exercises (A) and elevation (D) are supportive but secondary. Abdominal massage (B) is not indicated.
The nurse is assessing a 42-year-old client with cancer. He has lost 1 lb in 4 weeks. He is taking ondansetron (Zofran) for nausea. He has a temperature of 101°F (38.3°C). The fever is indicative of:
- A. Inadequate nutrition.
- B. New resistance to current antiemetic therapy.
- C. Expected response to chemotherapy treatment.
- D. Infection.
Correct Answer: D
Rationale: A fever of 101°F in a cancer patient, especially during chemotherapy, is most likely indicative of infection, which requires prompt evaluation due to immunosuppression.
A client with renal calculi is prescribed potassium citrate. The purpose is to:
- A. Dissolve stones.
- B. Alkalinize urine.
- C. Reduce pain.
- D. Prevent bleeding.
Correct Answer: B
Rationale: Potassium citrate alkalinizes urine, preventing uric acid stone formation.
A nurse is completing the health history for a client with the patient taking echinacea for a health care. The client asks, 'Why Isn't this helping me feel better?' Which of the following responses by the nurse would be the most accurate?
- A. There is limited information as to the effectiveness of herbal products.
- B. Antibiotics are the agents needed to treat a head cold.
- C. The head cold should be gone within the month.
- D. Combining herbal products with prescription antiviral medications is sure to help you.
Correct Answer: A
Rationale: At this time, there is no strong research evidence to warrant recommendations of herbal products for management of colds; further study is needed to show evidence of therapeutic effects and indications. Antibiotics are effective against bacteria; the head cold may have a viral cause. An uncomplicated upper respiratory tract infection subsides within 2 to 3 weeks. There may be a drug-drug interaction with herbal products and prescriptions.
When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which of the following physiologic functions?
- A. Bleeding tendencies.
- B. Intake and output.
- C. Peripheral sensation.
- D. Bowel function.
Correct Answer: A
Rationale: Aplastic anemia causes pancytopenia, including thrombocytopenia, which increases the risk of bleeding. The nurse should assess for bleeding tendencies, such as petechiae, bruising, or mucosal bleeding. Intake/output, sensation, and bowel function are not primarily affected.