A patient has difficulty raising pulmonary secretions, and the nurse writes a nursing diagnosis of "Ineffective Airway Clearance related to weak cough and fatigue." What would best help the patient maintain a clear airway?
a. Teach relaxation exercises.
b. Allow rest periods between activities.
c. Encourage fluids; suction prn as ordered.
d. Instruct in abdominal and pursed-lip breathing.
ANS: D
Fluids help reduce viscosity of secretions, and suction can remove secretions in patients who are unable to cough effectively. A. B. Rest and relaxation can help with activity intolerance and anxiety. D. Breathing exercises help correct impaired gas exchange.
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A nurse who works in a hospital clinic is describing ways of integrating genetics and genomics into nursing practice. Which of the following actions is most consistent with this role?
A) Planning treatment modalities for diseases that have patterns of inheritance B) Processing tissue samples to obtain genetic information C) Choosing options for patients after genetic testing has been completed D) Informing patients about the ethics of genetics and genomic concepts
When observing a mother during breastfeeding, the nurse detects a soft swallowing sound as the infant suckles. An appropriate comment to the mother would be:
a. "The two of you are doing very well!" b. "That sound means that you need to reposition the baby." c. "The baby does not have a good grasp on the nipple." d. "The baby is having trouble swallowing."
A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?
A) "Do they occur after you have been tense or anxious?" B) "When you consume alcohol, do you get a headache?" C) "Do you have any eye symptoms, such as tearing?" D) "Do you have any visual changes before the headache?"
A 32-year-old woman now at 32 weeks' gestation is complaining of right-sided sharp abdominal pain. The patient is examined by the clinic nurse and given information about abdominal discomfort in pregnancy
She is also instructed to seek immediate attention if she (select all that apply): a. Has heartburn b. Has chills or a fever c. Feels decreased fetal movements d. Has increased abdominal pain