Nokea
Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema?
- A. To promote oxygen intake.
- B. To strengthen the diaphragm.
- C. To strengthen the intercostal muscles.
- D. To promote carbon dioxide elimination.
Correct Answer: D
Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and promoting CO2 elimination in emphysema. It does not directly increase oxygen intake or strengthen muscles.
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A client with an ileal conduit should report:
- A. Mucus in urine.
- B. Stoma bleeding.
- C. Yellow urine.
- D. No odor.
Correct Answer: B
Rationale: Stoma bleeding is abnormal and may indicate trauma or infection.
A nurse is participating in a diabetes screening program. Who of the following is (are) at risk for developing type 2 diabetes? Select all that apply.
- A. A 32-year-old female who delivered a 9½-lb infant.
- B. A 44-year-old Native American Indian who has a body mass index (BMI) of 32.
- C. An 18-year-old Hispanic who jogs four times a week.
- D. A 55-year-old Asian American who has hypertension and two siblings with type 2 diabetes.
- E. A 12-year-old who is overweight.
Correct Answer: A,B,D,E
Rationale: Risk factors for type 2 diabetes include history of delivering a large infant, obesity (BMI >30), family history, hypertension, and being overweight, especially in youth. Regular exercise reduces risk, making the 18-year-old less likely to be at risk.
Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply.
- A. Checking urine for bright blood and a dark smoky color
- B. Daily walking as a good exercise
- C. Using garlic and ginger, which may decrease bleeding time
- D. Performing foot/leg exercises and walking around the airplane cabin on long flights
- E. Prevention as the best treatment for DVT
- F. Avoiding surface bumps because the skin is prone to injury
Correct Answer: A,B,D,F
Rationale: Rationales: A) Monitoring urine for bleeding is essential on anticoagulants. B) Daily walking promotes circulation, preventing DVT recurrence. D) Foot/leg exercises and movement during flights reduce stasis. F) Avoiding bumps prevents bruising/bleeding due to anticoagulant therapy. C) Garlic and ginger may increase bleeding risk, not decrease it. E) Prevention is vague and not a specific instruction.
A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to:
- A. Call for the physician.
- B. Start an I.V. line.
- C. Obtain a portable chest radiograph.
- D. Draw blood for laboratory studies.
Correct Answer: A
Rationale: Indigestion in a client with cardiac risk factors may indicate an MI. Calling the physician promptly ensures rapid evaluation and intervention, such as ECG or medications.
Galactorrhea is caused by overproduction of which hormone?
- A. Prolactin.
- B. Adrenocorticotropic hormone (ACTH).
- C. Growth hormone (GH).
- D. Thyroid-stimulating hormone (TSH).
Correct Answer: A
Rationale: Galactorrhea (inappropriate breast milk production) is caused by excess prolactin, often due to a prolactin-secreting pituitary adenoma.