Nokea
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 improving breathing. Side-lying (B), Reverse Trendelenburg (C), and Sims (D) are less effective for respiratory relief.
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A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which of the following statements is true concerning oxygen administration to a client with COPD?
- A. High oxygen concentrations will cause coughing and dyspnea.
- B. High oxygen concentrations may inhibit the hypoxic stimulus to breathe.
- C. Increased oxygen use will cause the client to become dependent on the oxygen.
- D. Administration of oxygen is contraindicated in clients who are using bronchodilators.
Correct Answer: B
Rationale: In COPD, high oxygen concentrations may suppress the hypoxic drive to breathe, risking CO2 retention. Oxygen does not cause coughing, dependency, or contraindication with bronchodilators.
A 36-year-old female is complaining of increased vaginal dryness during sexual intercourse. She has received chemotherapy in the past and has menopausal symptoms due to ovarian suppression. An appropriate nursing intervention would be to instruct the client on the use of:
- A. Vaginal dilators.
- B. Nightly douches.
- C. Water-soluble vaginal lubricants.
- D. Relaxation techniques.
Correct Answer: C
Rationale: Water-soluble vaginal lubricants are effective for managing vaginal dryness caused by chemotherapy-induced ovarian suppression, improving comfort during intercourse.
The American Heart Association (AHA) guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for:
- A. Early defibrillation in cases of atrial fibrillation.
- B. Cardiovascular placement.
- C. Early defibrillation in cases of ventricular fibrillation.
- D. None of the above
Correct Answer: C
Rationale: AEDs are used for early defibrillation in ventricular fibrillation or pulseless ventricular tachycardia, as these are shockable rhythms that can be corrected to restore cardiac function.
The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give 'hand-off reports' at which of the following times? Select all that apply.
- A. Change of shift.
- B. Change of nurses.
- C. When nurse goes to lunch.
- D. When unit clerk goes to a staff meeting.
- E. When new medication orders are written.
Correct Answer: A,B,C
Rationale: Hand-off reports are critical at change of shift, change of nurses, and when the nurse goes to lunch to ensure continuity of care and client safety.
Which activity should a client with an ileal conduit avoid?
- A. Swimming.
- B. Walking.
- C. Heavy lifting.
- D. Reading.
Correct Answer: C
Rationale: Heavy lifting can strain the stoma site, increasing hernia risk.