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Questions 158

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Extract:


Question 1 of 5

A client with a history of a hiatal hernia is being discharged. The nurse should teach the client to:

Correct Answer: C

Rationale: Carbonated beverages increase gastric pressure, worsening hiatal hernia symptoms. Sleeping upright, small meals, and avoiding lying down post-meals are also recommended.

Question 2 of 5

The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:

Correct Answer: D

Rationale: A large goiter can compress the trachea, posing a risk for ineffective airway clearance, which is a priority due to its potential to impair breathing.

Question 3 of 5

The nurse is caring for a client with a diagnosis of postpartum hemorrhage. Which vital sign change is most likely to be observed?

Correct Answer: C

Rationale: Postpartum hemorrhage causes significant blood loss leading to tachycardia (to compensate for reduced volume) and hypotension (from decreased perfusion). Both are common vital sign changes.

Question 4 of 5

The nurse is caring for a client with a history of type 2 diabetes. The nurse should expect the client to have:

Correct Answer: A

Rationale: Type 2 diabetes causes hyperglycemia, leading to polyuria due to osmotic diuresis.

Question 5 of 5

A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:

Correct Answer: C

Rationale: An adult diazepam dosage for treatment of anxiety is 2-10 mg PO 2-4 times daily. The order as written would place a client at risk for overdose. A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. Distraction will not prevent or control hyperventilation caused by anxiety or fear.

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