Which intervention should the nurse implement for the older client with Ineffective Airway Clearance as a result of pneumonia?
A. Incentive spirometry 5 to 10 breaths per session every hour while awake
B. Chest physiotherapy every 4 hours while awake
C. Positioning the client on the unaffected side
D. Oxygen at 45 L/minute by nasal cannula
A
Chest physiotherapy and positioning on the unaffected side have minimal if any benefit in as-sisting with airway clearance. Oxygen therapy does not contribute to airway clearance. Incentive spirometry facilitates deep breathing and stimulates coughing, both of which help clear the air-ways.
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A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this client's discharge teaching?
a. "You should change the batteries in your smoke detector once a year." b. "Join a program that assists burn clients to reintegration into the community." c. "I will demonstrate how to change your wound dressing for you and your family." d. "Let me tell you about the many options available to you for reconstructive surgery."
A nursing instructor is preparing a teaching plan for a class comparing evidence-based practice and critical thinking. Which of the following would the instructor include?
A) Evidence-based practice and critical thinking are polar opposites. B) Both involve problem clarification of central concepts. C) Critical thinking must occur before evidence-based practice begins. D) Problem exploration is unique to evidence-based practice.
Which nursing diagnosis has the highest priority for the infant with a congenital diaphragmatic hernia?
a. Risk for infection related to the immature immune system b. Imbalanced nutrition: less than body requirements related to NPO status c. Acute pain related to procedures and treat-ments d. Ineffective breathing pattern related to structural anomaly
Which laboratory result in a client with cancer who has gained 2 pounds in 1 day suggests the possibility of SIADH?
A. Serum potassium of 5.2 mmol/L B. Serum sodium of 120 mmol/L C. Hematocrit of 40% D. BUN of 10 mg/dL