A client who has been diagnosed with hypertension is being taught to restrict intake of sodium. The nurse would know that the teachings are effective if the client states that…
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Solution
I can eat shredded wheat cereal
Option C: Wheat cereal has a low sodium content.
George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in water-seal chamber, the nurse should…
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Solution
Check the system for air leaks
Option B: Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion.
Which nursing intervention ensures adequate ventilating exchange after surgery?
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Solution
Position client laterally with the neck extended
Option C: Positioning the client laterally with the neck extended does not obstruct the airway so that drainage of secretions and oxygen and carbon dioxide exchange can occur.
A female client is experiencing painful and rigid abdomen and is diagnosed with perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted. The nurse should place the client before surgery in
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Solution
Semi-fowlers position
Option C: Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity.
Which of the following statements should the nurse teach the neutropenic client and his family to avoid?
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Solution
Using suppositories or enemas
Option B: Neutropenic client is at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract.
Myrna a 52-year-old client with a fractured left tibia has a long leg cast and she is using crutches to ambulate. Nurse Joy assesses for which sign and symptom that indicates complication associated with crutch walking?
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Solution
Forearm weakness
Option D: Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae.
Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process of:
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Solution
Osmosis
Option A: Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration.
Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate the amount of fluid Jessie has lost…
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Solution
2.0 L
Option C: One liter of fluid approximately weighs 2.2 pounds. A 4.5 pound weight loss equals to approximately 2L.
Nurse Jamie should explain to male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because…
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Solution
More accurate
Option A: Urine testing provides an indirect measure that maybe influenced by kidney function while blood glucose testing is a more direct and accurate measure.
Nurse Lilly has been assigned to a client with Raynaud’s disease. Nurse Lilly realizes that the etiology of the disease is unknown but it is characterized by:
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Solution
Episodic vasospastic disorder of the small arteries
Option D: Raynaud’s disease is characterized by vasospasms of the small cutaneous arteries that involves fingers and toes.