Nokea
Why may it pose a challenge to supplement or restrict dietary consumption when providing health-related education to clients from culturally diverse populations?
- A. Cultural beliefs about food may conflict with dietary recommendations.
- B. Clients may prefer traditional healers over modern medicine.
- C. Language barriers may hinder understanding.
- D. All of the above.
Correct Answer: A
Rationale: Cultural beliefs significantly influence dietary habits, requiring sensitivity and adaptation in health education.
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During pulmonary hygiene for a client with pneumonia, a nurse positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: B
Rationale: The correct answer is B: Lateral segment of the right lower lobe. In Trendelenburg position on the left side, gravity helps drain secretions from the right lung's lateral segments more effectively. The right lower lobe's lateral segment is the most dependent part of the lung in this position, facilitating secretion mobilization. Choices A, C, and D are incorrect because they do not align with the gravitational effect in Trendelenburg position on the left side, making secretion mobilization less efficient in those segments.
What is your evaluation of Mr. Smith’s skin rash and slight fever after taking INH for 3 months?
- A. Is developing hepatitis
- B. Has not been taking INH
- C. Is having a normal response to the medication
- D. Is demonstrating early signs of drug hypersensitivity
Correct Answer: D
Rationale: The correct answer is D because Mr. Smith's skin rash and slight fever after taking INH for 3 months indicate early signs of drug hypersensitivity. This is supported by the timing of symptoms appearing after prolonged use, which is typical for drug hypersensitivity reactions. Other choices are incorrect: A, developing hepatitis would show different symptoms; B, not taking INH would not explain the symptoms; C, a normal response would not involve rash and fever.
A 35-year-old female client has returned to her room following surgery on her right femur. She has an IV of D5 1/2 NS infusing at 125 cc/hr, and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. The client last voided 5 1/2 hours ago when she was given her preoperative medication. To monitor and promote the return of urinary function after surgery, the nurse should:
- A. provide food and fluids at the client's request.
- B. maintain the IV, increasing the rate hourly until the client voids.
- C. report to the surgeon if the client is unable to void within 8 hours of surgery.
- D. hold the morphine sulfate injections for pain until the client voids, explaining to the client that morphine sulfate can cause urinary retention.
Correct Answer: C
Rationale: Provision of food and fluids promotes bowel elimination. Postoperative nutritional needs are physician determined, not client determined. Increasing IV fluids postoperatively will not cause a client to void. Any change in the rate of administration of IV fluids is determined by the physician, not the nurse. If the postoperative client with normal kidney function cannot void 8 hours after surgery, the client is retaining urine. The client may need catheterization or medication. The physician will provide orders for either, as necessary. While morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.
What strategies could decrease the distress of rotating shifts for nurses (select all that apply)?
- A. Take a brief onsite nap
- B. Use sleep hygiene practices
- C. Sleep just before going to work
- D. Maintain consistent sleep/wake schedules even on days off (if possible)
Correct Answer: A
Rationale: The correct answers are A, B, and D. Brief naps (A), sleep hygiene (B), and consistent schedules (D) improve adaptation to shift work. Sleeping just before work (C) can worsen sleep quality.
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
- A. Call the health care provider.
- B. Check vital signs.
- C. Position in high Fowler's.
- D. Administer oxygen.
Correct Answer: D
Rationale: Oxygen administration is immediate to address hypoxemia.