Your client needs to stretch all alveoli and increase the production of surfactant. The mechanism that causes this is called:
1. cough.
2. sneeze.
3. sigh.
4. recoil.
ANS: 3
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A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. The nurse should immediately:
1. Change the client's position in bed. 2. Notify the physician that birth is imminent. 3. Administer oxygen at 2 liters per minute. 4. Begin continuous fetal heart rate monitoring.
A client appears sad and speaks slowly and haltingly. She tells the nurse of the death of her husband
of 50 years and the death of her daughter in a recent automobile accident. The client has no other family but has a circle of close friends who offer support. What nursing diagnosis should be considered for this client? a. Spiritual distress related to being angry with God for taking her family b. Anxiety related to sudden and abrupt lifestyle change c. Social isolation related to loss of existing family d. No nursing diagnosis listed is warranted at this time
The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal tem-perature, is hypotensive, and has diarrhea
What is the nurse's best action? A. Nothing, because the findings are normal for clients during the acute phase of re-covery. B. Increase the temperature in the room and increase the IV infusion rate. C. Assess the client's airway and oxygen saturation. D. Notify the burn emergency team.
A client experiencing pain after surgery says "Something must be wrong," since the pain is so severe. The best response for the nurse to make to the client would be:
1. "The amount of tissue disrupted from the surgery is not related to the degree of pain you feel." 2. "That could be so." 3. "Taking pain medication for many years has made the medication ineffective now." 4. "Are you sure the pain is as bad as you are saying it is?"