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NEW QUESTION 36
A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:
- A. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20-24 times/min
- B. Purse the lips and take quick, short breaths approximately 18-20 times/min
- C. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through the nose.
Repeat 4-5 times to complete the series - D. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more times to complete the series every
1-2 hours while awake
Answer: D
Explanation:
Explanation
(A) This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. (B) Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. (C) Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. (D) Inhaling and exhaling at a rate of 20-24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.
NEW QUESTION 37
The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage.
These signs and symptoms would include:
- A. Feeling of eye pressure and headache
- B. Blurred vision and dizziness
- C. Eye discharge and hemoptysis
- D. Eye pain and itching
Answer: D
Explanation:
Section: Questions Set B
Explanation:
(A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B) Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not.
NEW QUESTION 38
Before giving methergine postpartum, the nurse should assess the client for:
- A. Afterpains
- B. Decreased amount of lochial flow
- C. Flushing
- D. Elevated blood pressure
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. (B) Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. (C) Flushing is not a side effect of methergine. (D) Afterpains are increased with methergine usage. The client should be informed that this is a normal response.
NEW QUESTION 39
After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son's circumcision?
- A. "I'll apply alcohol to the area daily to clean it and prevent any infection."
- B. "I'll keep a close watch on it for a day or two."
- C. "I'll make sure I soak the gauze with warm water first, before I take it off each time."
- D. "I'll make sure that I report any drainage around where they operated."
Answer: C
Explanation:
(A) Before petrolatum gauze is removed, it should be soaked with warm water to prevent trauma to adherent tissues. (B) A yellow exudate often forms normally over the surgical site. Only if it becomes foul-smelling and purulent would it need to be reported. (C) Alcohol should never be used on the site; this would be extremely painful to the infant. (D) Special care and observance should continue until the site is completely covered with clean, pink granulation tissue, which could take 7-10 days.
NEW QUESTION 40
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