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333666985
333666985
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
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 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 for meningitis. Inreviewing
the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to
note
a. high protein
b. clear color
FB Q & A #9 for NLE - A client complains of vertigo. The nurse anticipates 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 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 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 fowlers position will promote lung
expansion and effective coughing. While drinking liquids helps to loosen
secretions over time, they should not be given when collecting a specimen.
Spraying the throat with saline may cause irritation and coughing and reduce
oxygenation.
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.