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Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma?
- A. Incorporate physical exercise as tolerated into the daily routine.
- B. Monitor peak flow numbers after meals and at bedtime.
- C. Eliminate stressors in the work and home environment.
- D. Use sedatives to ensure uninterrupted sleep at night.
Correct Answer: A
Rationale: Regular exercise, as tolerated, improves lung function and overall health in asthma. Peak flow monitoring is typically done morning and evening. Eliminating all stressors is unrealistic. Sedatives may depress respiration and are not recommended.
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Which of the following positions would be appropriate for a client with severe ascites?
- A. Fowler's.
- B. Side-lying.
- C. Reverse Trendelenburg.
- D. Sims.
Correct Answer: A
Rationale: Fowler's position (A) elevates the head, reducing diaphragm pressure from ascites and aiding breathing. Side-lying (B), Reverse Trendelenburg (C), and Sims (D) are less effective.
A 79-year-old female client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would most like to a predisposing factor for the diagnosis of pneumonia?
- A. Age.
- B. Osteoarthritis.
- C. Vegetarian diet.
- D. Daily bathing.
Correct Answer: A
Rationale: Advanced age weakens the immune system and respiratory muscles, increasing pneumonia risk. Osteoarthritis, a vegetarian diet, and daily bathing do not directly predispose to pneumonia.
A client with diverticulosis asks about preventing flare-ups. Which recommendation should the nurse provide?
- A. Take a daily laxative to ensure regularity.
- B. Avoid nuts and seeds in the diet.
- C. Increase intake of red meat.
- D. Limit physical activity to reduce strain.
Correct Answer: B
Rationale: Avoiding nuts and seeds may reduce the risk of diverticulitis flare-ups by preventing irritation of diverticula, though evidence is mixed. Daily laxatives are not recommended, red meat is not restricted, and limiting activity is unnecessary. CN: Health promotion and maintenance; CL: Synthesize
The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the data, the nurse should?
- A. Change the appliance bag.
- B. Notify the physician.
- C. Obtain a urine specimen for culture.
- D. Encourage a high fluid intake.
Correct Answer: D
Rationale: Yellow urine with moderate mucus is normal for an ileal conduit due to intestinal segment use. Encouraging high fluid intake prevents complications like calculi or infection.
A 75-year-old client who has been taking furosemide (Lasix) regularly for 4 months tells the nurse that he is having trouble hearing. What would be the nurse's best response to this statement?
- A. Tell the client that because he is 75 years old, it is inevitable that his hearing should begin to deteriorate.
- B. Have the client immediately report the hearing loss to his physician.
- C. Schedule the client for audiometric testing and a hearing aid.
- D. Tell the client that the hearing loss is only temporary; when his system adjusts to the furosemide, his hearing will improve.
Correct Answer: B
Rationale: Furosemide can cause ototoxicity, leading to hearing loss. The nurse should advise the client to report this to the physician promptly for further evaluation and management.