Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will inhale slowly through pursed lips to help me breathe better."
Inhaling slowly through pursed lips is incorrect. The correct technique is to exhale slowly through pursed lips, which helps to keep the airways open longer, allowing for better air exchange and reducing shortness of breath.
B. "I will lie on my stomach to practice abdominal breathing every day."
Lying on the stomach to practice abdominal breathing is not a recommended strategy for managing emphysema. Abdominal or diaphragmatic breathing can be beneficial, but it is typically practiced in a comfortable, upright position.
C. "I will follow a daily diet high in calories and protein."
Clients with emphysema often have an increased caloric demand due to the effort required to breathe. A diet high in calories and protein can help maintain energy levels and prevent muscle wasting.
D. "I will avoid getting a flu shot."
Avoiding a flu shot is incorrect. Patients with emphysema are at higher risk for respiratory infections, and getting an annual flu shot is crucial to prevent complications.
This question is an excerpt from Nurse Dive's nursing test bank - ATI SP 250 Exam 3 Med Surg Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice C. “I will follow a daily diet high in calories and protein.”
Choice A rationale:
Inhaling slowly through pursed lips is incorrect. The correct technique is to exhale slowly through pursed lips, which helps to keep the airways open longer, allowing for better air exchange and reducing shortness of breath.
Choice B rationale:
Lying on the stomach to practice abdominal breathing is not a recommended strategy for managing emphysema. Abdominal or diaphragmatic breathing can be beneficial, but it is typically practiced in a comfortable, upright position.
Choice C rationale:
Clients with emphysema often have an increased caloric demand due to the effort required to breathe. A diet high in calories and protein can help maintain energy levels and prevent muscle wasting.
Choice D rationale:
Avoiding a flu shot is incorrect. Patients with emphysema are at higher risk for respiratory infections, and getting an annual flu shot is crucial to prevent complications.
Similar Questions
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
A. Soles of the feet
B. Ear lobes
C. Oral mucosa
This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.
D. Conjunctivae
Full Explanation
This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.
A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme- linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?
A. CD4+ T-cell count
B. Western blot analysis
This is because Western blot analysis detects specific antibodies to HIV antigens and has a high specificity and sensitivity for HIV infection. CD4+ T-cell count measures the number of helper T cells in the blood and indicates the degree of immunosuppression in clients with HIV infection, but it does not confirm the diagnosis. Quantitative RNA assay and viral load test measure the amount of HIV RNA in the blood and indicate the level of viral replication and response to antiretroviral therapy, but they do not confirm the diagnosis.
C. Quantitative RNA assay
D. Viral load test
Full Explanation
This is because Western blot analysis detects specific antibodies to HIV antigens and has a high specificity and sensitivity for HIV infection. CD4+ T-cell count measures the number of helper T cells in the blood and indicates the degree of immunosuppression in clients with HIV infection, but it does not confirm the diagnosis. Quantitative RNA assay and viral load test measure the amount of HIV RNA in the blood and indicate the level of viral replication and response to antiretroviral therapy, but they do not confirm the diagnosis.
A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)?
A. 9 percent
B. 18 percent
C. 36 percent
This is because according to the rule of nines, each arm accounts for 9 percent and each leg accounts for 18 percent of the TBSA. Therefore, burns on both arms and both legs equal (9+9+18+18) =54%.
D. 54 percent
Full Explanation
This is because according to the rule of nines, each arm accounts for 9 percent and each leg accounts for 18 percent of the TBSA. Therefore, burns on both arms and both legs equal (9+9+18+18) =54%.