The nurse is caring for a postoperative patient who has a nursing diagnosis of ineffective airway clearance. Which of these outcomes would be most appropriate for this patient?
a. Observes demonstration of coughing and deep breathing exercises
b. Explains coughing and deep breathing exercises
c. Explains rationale for coughing and deep breathing exercises
d. Correctly demonstrates coughing and deep breathing exercises
ANS: D
To clear the airway, effective coughing and deep breathing are needed, and demonstration is the best method for verifying correct technique. The airway will not be cleared with A, B, and C.
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The nurse is caring for a patient who is prescribed an antidepressant. The patient asks the nurse how the drug works. Which is the best response by the nurse?
1. "The medication will target neurotransmitters in the stomach." 2. "The medication will target specific cells in the central nervous system." 3. "The medication will enter your bloodstream and find the targeted area." 4. "The medication will target your central nervous system as a whole."
An older patient is diagnosed with a disease caused by a secondary immunodeficiency disorder. For which disorders should the nurse be prepared to plan care? Standard Text: Select all that apply
1. HIV 2. Cirrhosis 3. Medications 4. Malnutrition 5. Diabetes mellitus
The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for the newborn at home
Which instructions should the nurse emphasize? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Use proper hand-washing technique. 2. Provide three feedings per day. 3. Place soiled diapers in a sealed plastic bag. 4. Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. 5. Take the temperature rectally.
The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which of the following arterial blood gas (ABG) findings?
1. pH, 7.40; PaO2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L 2. pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L 3. pH, 7.47; PaO2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L 4. pH, 7.31; PaO2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L