FB Q & A #4 for NLE - A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should: a. turn the client every 2 hours b. elevate the head of the bed 30... degrees c. encourage increased fluid intake d. maintain a cool room temperature temperature
FB Q & A #6 for NLE - An elderly client with tuberculosis has difficulty coughing up secretions for a sputum specimen. Which nursing action act ion is appropriate? a. spray the oropharynx w ith saline b. ask the client c lient to drink a warm liquid c. force fluids for the next 8 hours d. raise the head of the bed to at least 45 degrees
FB Q & A #15 for NLE - The nurseis teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse noticesredness, swelling, and induration at the wound site. What do these signs suggest? a. infection b. dehiscence c. hemorrhage d. evisceration FB Q & A #14 for NLE - The nurse administers furosemide (Lasix) to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully? a. increase in blood pressure b. increase in blood volume c. low serum potassium level d. high serum sodium level FB Q & A #13 for NLE - The nurseshould be prepared to manage complications after abdominal aortic aneurysm resection. Which of the following complications is most common postoperatively? a. renal failure b. hemorrhage and shock c. graft occlusion d. enteric fistula FBQ & A #11 for NLE - A client has been admitted adm itted for meningitis. Inreviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note a. high protein b. clear color
c. elevated sedimentation rate d. increased glucose FB Q & A #6 for NLE - An elderly client with tuberculosis has difficulty coughing up secretions for a sputum specimen. Which nursing action is appropriate? a. spray the oropharynx with saline FB Q & A #4 for NLE - A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should: a. turn the client every 2 hours b. elevate the head of the bed 30... degrees c. encourage increased fluid intake d. maintain a cool room temperature -Answer: C Rationale: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would decrease pooling of secretions but wouldn't liquefy them. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't liquefy secretions. Maintaining a cool room temperature would increase the client's comfort but wouldn't liquefy secretions.
FB Q & A #10 for NLE - For a client with a head injury whose neck has been stabilized, the preferred bed position is: a. trendelenburg's b. 30-degree head elevation ...c. flat d. side-lying
FB Q & A #9 for NLE - A client complains of vertigo. The nurse anticipates antici pates that the client may have a problem with which portion of the ear? a. external ear b. middle ear
c. inner ear d. tympanic membrane FB Q & A #8 for NLE - The nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what major complication of ICP monitoring? a. coma b. infection c. high blood pressure d. apnea -Answer: B Rationale: The catheter for measuring me asuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP.
FB Q & A #7 for NLE - The nurse is removing rem oving a fecal impaction on a75 year-old client. It is most important that the nurse remember that: a. the procedure be done prior to the bath b. family members should be taught the procedure c. cardiac dysrhythmias can result during the process d. increased dietary fiber can minimi...ze such problem FB Q & A #6 for NLE - An elderly client with tuberculosis has difficulty coughing up secretions for a sputum specimen. Which nursing action is appropriate? a. spray the oropharynx with saline b. ask the client to drink a warm liquid c. force fluids for the next 8 hours d. raise the head of the bed to at least 45 degree...s -The correct answer is D: Raise the head of the bed to at least 45 degrees Rationale: Placing the client in semi or high fowler¶s position will promote lung expansion and effective coughing. While drinking liquids helps to loosen secretions over time, they should not be given gi ven when collecting a specimen. Spraying the throat with saline may cause irritation ir ritation and coughing and reduce oxygenation.
FB Q & A #5 for NLE - To evaluate a client's chief complaint, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following? FB Q & A #4 for NLE - A client hospitalized with pneumonia has thick, tenacious secretions. secr etions. To help liquefy these secretions, the nurse should: a. turn the client every 2 hours b. elevate the head of the bed 30 ... degrees c. encourage increased fluid intake d. maintain a cool room temperature
B Q & A #3 for NLE - Whenmonitoring a client's central centr al venous pressure (CVP), the nurse knows that anormal CVP measurement is: a. 2 cm water b. 1 mm Hg c. 10 mm Hg d. 5 cm water -Rationale for Question Number 2 - The client should be encouraged to force fluids to prevent renal calculi formation. Sodium should be encouraged to replace losses in urine. Restricting potassium isn't necessary in hyperparathyroidism. -Answer for Question #2 - Letter C
Rationale for Question #1 - In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia. In SIADH, the serum creatinine level isn't affected by the client's fluid status and re...mains within normal limits. Typically, the hematocrit and BUN level decrease.
-Answer for Question #1 - Letter A
FB Q & A #12 for NLE - The nurse would teach a client with Raynaud's phenomenon that it is most important to: a. stop smoking b. keep feet dry c. reduce stress d. avoid caffeine -Answer is Letter A: Stop smoking The most important teaching for this client is to stop
smoking. The question is asking what is the most important teaching. The others tend to be done less frequently than smoking and are less of a threat.
