Nokea
Which of the following measures would most likely be successful in reducing pleuritic chest pain in a client with pneumonia?
- A. Encourage the client to breathe shallowly.
- B. Have the client practice abdominal breathing.
- C. Offer the client inceptive spirit.
- D. Teach the client to splint the rib cage when coughing.
Correct Answer: D
Rationale: Splinting the rib cage during coughing stabilizes the chest, reducing pleuritic pain. Shallow breathing may worsen atelectasis. Abdominal breathing aids ventilation but not pain. 'Inceptive spirit' is likely a typo for incentive spirometry, which promotes lung expansion but not direct pain relief.
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A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? Select all that apply.
- A. Mailing eye examinations every 6 months.
- B. Maintaining follow-up monitoring of liver enzymes.
- C. Decreasing protein intake in the diet.
- D. Avoiding alcohol intake.
- E. The urine may have an orange color.
Correct Answer: B,D,E
Rationale: Rifampin requires liver enzyme monitoring (B) and alcohol avoidance (D) due to hepatotoxicity risk. Orange urine (E) is a harmless side effect. Eye exams and reduced protein intake are not indicated.
A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care?
- A. Remove the dressing and leave the incision open to air.
- B. Remove the drain if wound drainage is minimal.
- C. Gently irrigate the drain to remove exudate.
- D. Clean the area around the drain moving away from the drain.
Correct Answer: D
Rationale: When providing wound care, the nurse should clean the area around the drain moving away from the drain to prevent introducing pathogens into the wound. Leaving the incision open, removing the drain, or irrigating are not appropriate without specific orders. CN: Physiological adaptation; CL: Synthesize
A client with uric acid stones is prescribed a low-purine diet. Which food is allowed?
- A. Liver.
- B. Chicken.
- C. Apples.
- D. Sardines.
Correct Answer: C
Rationale: Apples are low in purines, suitable for a uric acid stone diet.
A client with a lumbar spinal fusion is preparing for discharge. Which activity should the nurse advise the client to avoid?
- A. Walking short distances daily.
- B. Lifting objects heavier than 10 pounds.
- C. Sleeping on a firm mattress.
- D. Using a recliner for sitting.
Correct Answer: B
Rationale: Lifting heavy objects can strain the surgical site, delaying healing post-spinal fusion.
Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma at all times. The client has been applying the skin barrier correctly when:
- A. There is no odor from the stoma.
- B. The client is adequately hydrated.
- C. There is no skin irritation around the stoma.
- D. The client only changes the ostomy pouch once a day.
Correct Answer: C
Rationale: Correct application of a skin barrier is indicated by no skin irritation around the stoma, as the barrier protects the peristomal skin. Odor, hydration, and pouch change frequency are not direct indicators of proper barrier use. CN: Physiological adaptation; CL: Evaluate