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Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.
- A. Encourage the client to splint the abdomen when coughing.
- B. Administer acetaminophen.
- C. Administer ondansetron.
- D. Remind the client to use the incentive spirometer five times per hr.
- E. Encourage the client to cough and deep breathe.
- F. Plan to ambulate the client 30 min after the next analgesic is administered.
Correct Answer: A,D,E,F
Rationale: A: Splinting reduces pain during coughing. D: Incentive spirometry prevents atelectasis. E: Coughing and deep breathing clear secretions. F: Ambulation post-analgesic promotes lung expansion.
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A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I should move my stronger leg forward before moving my weaker leg.
- C. I will move the cane forward 18 inches.
- D. I will hold the cane on my stronger side.
Correct Answer: B
Rationale: Moving the stronger leg first is correct for safe ambulation with a quad cane.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink two hot cups of coffee each morning.
- B. I take a prescribed opioid pain medication at bedtime.
- C. I love to eat apples and black-eyed peas.
- D. I drink an average of 2,000 milliliters of water daily.
Correct Answer: B
Rationale: Opioids slow bowel motility, increasing constipation risk.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
- C. Cleanse the wound with cotton balls.
- D. Dry the wound bed with gauze squares.
Correct Answer: B
Rationale: Holding the syringe 2.5 cm above ensures effective irrigation without contamination.
A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?
- A. Passive range-of-motion exercise
- B. Bowling
- C. Walking
- D. Jogging
Correct Answer: C
Rationale: Walking is a weight-bearing, low-impact exercise that helps improve bone density and is safe for osteoporosis prevention.
A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. Why don't you just file a formal complaint with Human Resources?
- B. So, you are upset about all of the recent changes on the unit?
- C. There has been too much complaining about these changes.
- D. Please, try to wait a little longer. Things will get better soon.
Correct Answer: B
Rationale: Reflective listening acknowledges the AP’s feelings and encourages discussion.