When discussing breathing exercises with a postoperative client, Nurse Hazel should include which of the following teaching?
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Solution
Place hand on the abdomen and feel it rise
Option D: Abdominal breathing improves lungs expansion
When suctioning an unconscious client, which nursing intervention should the nurse prioritize in maintaining cerebral perfusion?
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Solution
Hyperoxygenate before and after suctioning
Option D: It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion.
A Client with glaucoma has been prescribed with miotics. The nurse is aware that miotics is for:
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Solution
Constricting pupil
Option A: Miotic agent constricts the pupil and contracts ciliary muscle. These effects widen the filtration angle and permit increased outflow of aqueous humor.
A client has undergone surgery for retinal detachment. Which of the following goal should be prioritized?
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Solution
Prevent an increased intraocular pressure
Option A: After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal.
A client with peptic ulcer is being assessed by the nurse for gastrointestinal perforation. The nurse should monitor for:
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Solution
Sudden, severe abdominal pain
Option C: Sudden, severe abdominal pain is the most indicative sign of perforation. When perforation of an ulcer occurs, the nurse maybe unable to hear bowel sounds at all.
A client is suffering from low back pain. Which of the following exercises will strengthen the lower back muscle of the client?
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Solution
Swimming
Option D: Walking and swimming are very helpful in strengthening back muscles for the client suffering from lower back pain.
A client has undergone bone biopsy. Which nursing action should the nurse provide after the procedure?
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Solution
Monitor the site for bleeding, swelling and hematoma formation
Option C: Nursing care after bone biopsy includes close monitoring of the punctured site for bleeding, swelling and hematoma formation.
Nurse Becky is caring for client who begins to experience seizure while in bed. Which action should the nurse implement to prevent aspiration?
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Solution
Position the client on the side with head flexed forward
Option A: Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions, therefore, prevents aspiration.
Which of the following is not a sign of thromboembolism?
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Solution
Coolness
Option D: The client with thromboembolism does not have coolness.
Among the following, which client is autotransfusion possible?
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Solution
Client who is in danger of cardiac arrest
Option C: Autotransfusion is acceptable for the client who is in danger of cardiac arrest.