Nokea
Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress?
- A. Administering oxygen every 2 hours.
- B. Turning the client every 4 hours.
- C. Administering sedatives to promote rest.
- D. Suctioning if cough is ineffective.
Correct Answer: D
Rationale: Suctioning clears secretions when coughing is ineffective in ARDS, maintaining airway patency. Oxygen delivery, turning, and sedatives are supportive but less direct for airway clearance.
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Which of the following clinical manifestations does the nurse most likely observe in a client with Hodgkin's disease?
- A. Difficulty swallowing.
- B. Painless, enlarged cervical lymph nodes.
- C. Difficulty breathing.
- D. A feeling of fullness over the liver.
Correct Answer: B
Rationale: Hodgkin's disease typically presents with painless, enlarged cervical lymph nodes, often the first sign noticed. Difficulty swallowing, breathing, or liver fullness are less common or occur later.
A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should:
- A. Position the client on a firm mattress
- B. Keep the involved extremity warm with blankets
- C. Position the left leg at or below the body's horizontal plane
- D. Encourage the client to raise and lower his leg four times every hour
Correct Answer: C
Rationale: Positioning the left leg at or below the body's horizontal plane promotes arterial blood flow to the extremity in arteriosclerosis, avoiding gravitational resistance. A firm mattress is irrelevant, warmth is beneficial but secondary, and leg raises may not be feasible pre-revascularization.
The nurse should instruct the client to avoid which of the following drugs while taking metoclopramide hydrochloride (Reglan)?
- A. Antihypertensives.
- B. Anticoagulants.
- C. Alcohol.
- D. Cimetidine.
Correct Answer: C
Rationale: Alcohol can enhance the sedative effects of metoclopramide and worsen gastrointestinal symptoms, so it should be avoided.
Which of the following activities should the nurse teach the client to implement after the removal of nasal packing on the second postoperative day?
- A. Avoid cleaning the nares until swelling has subsided.
- B. Apply water-soluble jelly to lubricate the nares.
- C. Keep a nasal drip pad in place to absorb secretions.
- D. Use a bulb syringe to gently irrigate nares.
Correct Answer: B
Rationale: Applying water-soluble jelly lubricates the nares, preventing crusting and discomfort post-packing removal. Cleaning is safe once packing is removed. A drip pad is unnecessary unless bleeding persists. Irrigation with a bulb syringe is not standard care.
A client on hemodialysis reports muscle cramps. The nurse should:
- A. Increase dialysate flow.
- B. Check electrolyte levels.
- C. Administer a diuretic.
- D. Encourage ambulation.
Correct Answer: B
Rationale: Muscle cramps may indicate electrolyte imbalances, requiring lab assessment.