Question

The nurse recognizes that the most appropriate reason to suction a client is that:

Answer 1

Correct Answers:

the client has gurgling respirations, and is unable to cough.

Rationale :

Suctioning is indicated when a client cannot clear secretions effectively, leading to airway obstruction. Gurgling respirations suggest the presence of excessive secretions that the client cannot clear independently, which can lead to hypoxia or aspiration. Routine suctioning is not recommended as it can cause mucosal damage and increased secretions.

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Answer 2

Correct Answers:

Performing

Rationale :

The "performing" stage of group development is when the team functions effectively towards common goals. At this stage, the group has moved past conflicts (storming), established norms (norming), and is now highly productive.

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Answer 3

Correct Answers:

a need for perfectionism and control

Rationale :

Under delegation often happens because nurses feel they can do the task better or faster themselves. Perfectionism and control issues prevent effective delegation, which can lead to nurse burnout.

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Answer 4

Correct Answers:

Restrict sodium in the diet
Monitor vital signs
Monitor intake and output.

Rationale :

Hypernatremia results from excessive sodium intake or water loss. Management includes sodium restriction, monitoring fluid balance, and vital signs to detect complications like hypertension or dehydration.

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Answer 5

Correct Answers:

slow absorption of the drug

Rationale :

Cold application causes vasoconstriction, reducing blood flow to the area. This leads to slower absorption of topical drugs, prolonging their effect and reducing the risk of systemic side effects. This principle is often used for pain relief and inflammation control.

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Answer 6

Correct Answers:

RLQ

Rationale :

The appendix is located in the right lower quadrant (RLQ) of the abdomen. Appendicitis, an inflammation of the appendix, commonly presents with pain in this area, particularly at McBurney's point (a point one-third of the way from the anterior superior iliac spine to the umbilicus). Other quadrants—LUQ (left upper quadrant) and LLQ (left lower quadrant)—do not correspond with the appendix's anatomical location. "RI-JQ" is not a standard anatomical abbreviation.

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Answer 7

Correct Answers:

Lower conjunctival sac

Rationale :

When administering eyedrops, the correct technique is to instill the medication into the lower conjunctival sac (the pocket between the lower eyelid and the eye). This method ensures proper absorption and minimizes discomfort or injury to the cornea. Placing drops directly on the cornea can cause irritation and reflex blinking, while the sclera (outer or inner canthus) is not the intended site for medication delivery.

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Answer 8

Correct Answers:

inhales slowly to raise the ball to the desired level, and attempts to keep the ball raised for several seconds

Rationale :

The incentive spirometer is a device used to encourage deep breathing and lung expansion, often after surgery or during respiratory illness. The correct technique involves slow and steady inhalation through the mouthpiece, which raises the indicator ball to the desired level. Holding the breath for several seconds helps keep the alveoli open, preventing atelectasis (lung collapse) and promoting oxygen exchange.

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Answer 9

Correct Answers:

Dulcolax suppository one per rectum PRN
Fentanyl 25 mcg/h via transdermal patch daily
Morphine mg IV q4h PRN severe pain

Rationale :

The first-pass effect occurs when a drug is metabolized in the liver before reaching systemic circulation, reducing its bioavailability. Oral medications (A & C) undergo this effect. Rectal (B), transdermal (D), and intravenous (E) routes bypass the liver's first-pass metabolism, allowing the drug to act more efficiently.

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Answer 10

Correct Answers:

Assisting the client to maintain an adequate fluid intake

Rationale :

Hydration is the key to thinning secretions. Fluids help loosen mucus, making it easier to cough up. Oxygen therapy does not thin mucus, room temperature does not impact secretions significantly, and lying supine may make it harder to clear the airway.

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Nursing 100 day~Exam 4 Fundamentals

No.

1 : The nurse recognizes that the most appropriate reason to suction a client is that:

2 : A group that has transformed itself from a collection of individuals into a productive, problem-solving highly functioning team would be functioning in which stage of group development?

3 : The nurse is aware that a common cause of under delegation in client care is:

4 : A nurse is caring for a client being treated for hypernatremia.

Which of the following are appropriate nursing interventions?

(SELECT ALL THAT APPLY)

5 : The nurse has applied a topical agent to the client's skin, and then applies an ice pack to the area. This is done to:

6 : A client is admitted to the hospital with a diagnosis of RIO appendicitis. Which abbreviation would describe the location of a client's appendix?

7 : A client must receive eyedrops bilaterally four times a day. The medication should be dropped onto which of the following areas?

8 : The nurse knows that teaching about the use of the spirometer incentive is effective when the client seals the lips around the mouthpiece and:

9 : The nurse is administering medications to a client who has severe liver damage. Which medications, as ordered below, will avoid the first pass effect? (SELECT ALL THAT APPLY)

10 : Which nursing action is most helpful in thinning a client's thick respiratory secretions?

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Nursing 100 day~Exam 4 Fundamentals

No.

1 : The nurse recognizes that the most appropriate reason to suction a client is that:

2 : A group that has transformed itself from a collection of individuals into a productive, problem-solving highly functioning team would be functioning in which stage of group development?

3 : The nurse is aware that a common cause of under delegation in client care is:

4 : A nurse is caring for a client being treated for hypernatremia.Which of the following are appropriate nursing interventions?(SELECT ALL THAT APPLY)

5 : The nurse has applied a topical agent to the client's skin, and then applies an ice pack to the area. This is done to:

6 : A client is admitted to the hospital with a diagnosis of RIO appendicitis. Which abbreviation would describe the location of a client's appendix?

7 : A client must receive eyedrops bilaterally four times a day. The medication should be dropped onto which of the following areas?

8 : The nurse knows that teaching about the use of the spirometer incentive is effective when the client seals the lips around the mouthpiece and:

9 : The nurse is administering medications to a client who has severe liver damage. Which medications, as ordered below, will avoid the first pass effect? (SELECT ALL THAT APPLY)

10 : Which nursing action is most helpful in thinning a client's thick respiratory secretions?

4 : A nurse is caring for a client being treated for hypernatremia.

Which of the following are appropriate nursing interventions?

(SELECT ALL THAT APPLY)