Nokea
Which of the following nursing interventions would be most helpful in making the respiratory effort of a client with metastatic lung cancer more efficient?
- A. Teaching the client diaphragmatic breathing techniques.
- B. Administering cough suppressants as ordered.
- C. Teaching and encouraging pursed-lip breathing.
- D. Placing the client in a low semi-Fowler's position.
Correct Answer: C
Rationale: Pursed-lip breathing helps prolong exhalation, reducing air trapping and improving respiratory efficiency in clients with metastatic lung cancer.
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An older adult takes two 81 mg aspirin tablets daily to prevent a heart attack. The client reports having a constant 'ringing' in both ears. How should the nurse respond to the client's comment?
- A. Tell the client that 'ringing' in the ears is associated with the aging process.
- B. Refer the client to have a hearing test.
- C. Schedule the client for audiometric testing.
- D. Explain to the client that the 'ringing' may be related to the aspirin.
Correct Answer: D
Rationale: Aspirin, even at low doses, can cause tinnitus (ringing in the ears) as a side effect. The nurse should explain this potential link and advise consulting the physician.
After the nurse teaches a client about wearing a back brace after a spinal fusion, which of the following client statements indicates effective teaching?
- A. I will apply lotion before putting on the brace.'
- B. I will be sure to pad the area around my iliac crest.'
- C. I will use baby powder under the brace to absorb perspiration.'
- D. I will wear a thin cotton undershirt under the brace.'
Correct Answer: D
Rationale: A thin cotton undershirt prevents skin irritation while allowing the brace to fit properly.
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
- A. Preventing constipation.
- B. Administering lactulose (Cephulac).
- C. Monitoring coordination while walking.
- D. Checking the pupil reaction.
- E. Increasing food and fluids high in carbohydrate.
- F. Encouraging physical activity.
Correct Answer: A,B
Rationale: Preventing constipation (A) and administering lactulose (B) reduce ammonia levels in hepatic encephalopathy. Coordination (C) and pupil reaction (D) are less relevant. High carbohydrates (E) are not specific, and physical activity (F) may be limited.
Which information should the nurse include when developing a teaching plan for a client newly diagnosed with type 2 diabetes mellitus. Select all that apply.
- A. A major risk factor for complications is obesity and central abdominal obesity.
- B. Supplemental insulin is mandatory for controlling the disease.
- C. Exercise increases insulin resistance.
- D. The primary nutritional source requiring monitoring in the diet is carbohydrates.
- E. Annual eye and foot examinations are recommended by the American Diabetes Association (ADA).
Correct Answer: A,D,E
Rationale: Obesity, especially central, is a major risk factor for complications. Carbohydrates require monitoring to manage blood glucose. Annual eye and foot exams are recommended. Insulin is not mandatory for type 2 diabetes, and exercise decreases insulin resistance.
The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. Which is the priority nursing action?
- A. Activate the rapid response team.
- B. Assess the client's orientation and vital signs.
- C. Administer a bolus of lidocaine.
- D. Notify the physician.
Correct Answer: B
Rationale: PVCs every other beat (bigeminy) may indicate serious irritability. Assessing orientation and vital signs first determines the client's stability, guiding further actions.