The nurse has given instructions on pursed lip breathing to a client with emphysema. Which statement by the client would indicate effective teaching?
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Solution
Answer C is correct. Contracting the abdominal muscles with each exhalation is the proper technique for pursed lip breathing. Answers A, B, and D are all incorrect techniques. The goal is to increase the exhalation phase.
A client has returned to the surgical unit after a laryngectomy. When suctioning the tracheostomy, the nurse should not allow the suction pressure to exceed which level?
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Solution
Answer A is correct. The suction source should not exceed 120mmHg when performing tracheal suctioning. The answers in B, C, and D exceed this amount and could cause damage to the trachea.
It is essential that the nurse have which piece of equipment at the bedside of a client on a ventilator?
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Solution
Answer C is correct. The essential piece of equipment is the Ambu bag (manual resuscitator). Ventilator clients must always have another means of ventilation, in case of a problem with the ventilator, power, and so on. Answers A and B would be needed, but not as much as answer C. Answer D would be inappropriate for a client on the ventilator.
A client with seizures has jerking of the right arm and twitching of the face, but remains alert and aware of the seizure. This behavior is characteristic of which type of seizure?
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Solution
Answer C is correct. Simple partial seizures are characterized by the stated symptoms. Answers A and D are not characterized by these clinical manifestations. In answer B, a complex partial seizure, the client is not aware of the seizure.
The nurse recognizes that Nimotop (Nimodipine) is given to clients with aneurysms for which of the following reasons?
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Solution
Answer A is correct. Nimotop is a calcium channel blocker and is used to prevent the calcium influx. The etiology of vasospasm of the blood vessel has been thought to relate to this calcium influx; therefore, the drug is given to prevent this. Answers B, C, and D do not describe the action of this drug.
The influenza vaccine cannot be given to clients in which age group?
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Solution
Answer A is correct. The flu vaccine has not been found to be safe in children younger than 6 months; therefore, is not recommended for them. It is especially important that the vaccine be given in the age groups in answers B and D because they are high-risk groups. The age group in C is not a high-risk group, but flu vaccine administration is not contraindicated.
The client is admitted with a chest injury. The nurse’s assessment reveals that an area over the right clavicle is puffy and that there is a “crackling” noise with palpation. The nurse should further assess the client for which of the following problems?
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Solution
Answer D is correct. The stem is describing subcutaneous emphysema (answer B), which is a symptom of air escaping. This can occur with a pneumothorax; therefore, the client should be further assessed for this problem. Answer A is another type of chest trauma, and answer C is not an appropriate assessment from the information given.
The nurse is caring for a client with an acoustic neuroma brain tumor. The location of this tumor warrants particular concern for which of the following?
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Solution
Answer D is correct. An acoustic neuroma tumor is one of the eighth cranial nerves. This cranial nerve deals with balance, hearing, and coordination, making the client at risk for injury from falls. Answers A, B, and C are not appropriate priorities with the information given in the stem.
The LPN/LVN is caring for a client with a diagnosis of diabetes insipidus. Which of the following clinical manifestations is expected?
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Solution
Answer A is correct. Symptoms of diabetes insipidus include excretion of large amounts of dilute urine and extreme thirst. The clinical manifestations listed in options B, C, and D are not associated with diabetes insipidus so they are incorrect.
A client receiving a magnetic resonance imaging procedure should have which of the following implemented?
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Solution
Answer C is correct. An MRI uses a powerful magnetic force; therefore, any metal or jewelry should be removed before this test. Answers A, B, and D are not appropriate for this test.