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When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift the patient.
- A. While inhaling through an open mouth.
- B. While exhaling through pursed lips.
- C. After exhaling but before inhaling.
- D. While taking a deep breath and holding it.
Correct Answer: B
Rationale: Lifting while exhaling through pursed lips conserves energy by aligning effort with prolonged exhalation, reducing air trapping in COPD. Other methods increase respiratory workload.
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A client with bladder cancer has lost an estimated 500 mL blood in the urine. The client's hemoglobin is 8.0 g/dL, and the physician orders a unit of packed blood cells. To administer the packed red blood cells, the nurse should:
- A. Attach the packed cells to the existing 19G I.V. of normal saline solution using Y tubing.
- B. Start an additional 22G I.V. site because the packed blood cells must be given in a separate line.
- C. Attach the packed blood cells to the existing 22G I.V. of 5% dextrose using Y tubing.
- D. Start an additional I.V. access device with a 22G Intracath.
Correct Answer: A
Rationale: Packed red blood cells should be administered via a 19G I.V. with normal saline using Y tubing to prevent hemolysis, which can occur with dextrose solutions.
Which intervention supports a client with expressive aphasia?
- A. Speak loudly.
- B. Use written instructions.
- C. Provide a communication board.
- D. Ask complex questions.
Correct Answer: C
Rationale: A communication board supports communication for clients with expressive aphasia.
The nurse is developing a care plan with an older adult and is instructing the client that hypertension can be a silent killer. The nurse should instruct the client to be aware of signs and symptoms of other system failures and encourage the client to report signs of which of the following diseases that are often a result of undetected high blood pressure?
- A. Cerebrovascular accidents (CVAs).
- B. Liver disease.
- C. Myocardial infarction.
- D. Pulmonary disease.
Correct Answer: A,C
Rationale: Hypertension increases the risk of cerebrovascular accidents (A) and myocardial infarction (C), as it damages blood vessels, leading to stroke or heart attack.
What is a goal of care for a client with acute renal failure?
- A. Maintain urine output of 30 mL/hour.
- B. Keep potassium above 5.5 mEq/L.
- C. Increase protein intake.
- D. Limit ambulation.
Correct Answer: A
Rationale: Maintaining adequate urine output indicates improving renal function.
A client with colon cancer is scheduled for chemotherapy post-resection. Which of the following should the nurse monitor for as a common side effect of chemotherapy?
- A. Hypertension.
- B. Nausea and vomiting.
- C. Hyperglycemia.
- D. Joint pain.
Correct Answer: B
Rationale: Nausea and vomiting are common side effects of chemotherapy due to its impact on rapidly dividing cells, including those in the gastrointestinal tract. Hypertension, hyperglycemia, and joint pain are less commonly associated with chemotherapy. CN: Pharmacological and parenteral therapies; CL: Analyze