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Question 1 of 5

Which finding is the best indication that a client with ineffective airway clearance needs suctioning?

Correct Answer: C

Rationale: Adventitious breath sounds (e.g., rhonchi or gurgling) indicate mucus obstruction, making suctioning necessary to clear the airway.

Question 2 of 5

The nurse is teaching the client with AIDS regarding needed changes in food preparation. Which statement indicates that the client understands the nurse's teaching?

Correct Answer: B

Rationale: Thoroughly cooking meat reduces the risk of foodborne infections, which is critical for clients with AIDS due to their weakened immune systems.

Question 3 of 5

An elderly preoperative client seems very anxious but denies concerns when the nurse asks; however, the client's son confides that the client is very superstitious and believes it is bad luck that he is in room 113. Which of the following actions is the best response?

Correct Answer: B

Rationale: Reassigning the client to a different room (
B) addresses the client's anxiety by respecting his superstitious beliefs, promoting comfort. Reassurance (
A), medication (
C), or family presence (
D) may not fully alleviate the specific concern.

Question 4 of 5

A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

Correct Answer: D

Rationale: Radiation safety protocols limit visitation to short periods (e.g., 30 minutes) to minimize exposure to radioactive implants.

Question 5 of 5

The nurse is auscultating a client's breath sounds. Low-pitched grating and rubbing are noted on inhalation and exhalation. What will the nurse chart under assessment findings?

Correct Answer: C

Rationale: Low-pitched grating/rubbing sounds indicate a pleural friction rub, often due to pleural inflammation.

Similar Questions

The nurse is assessing an older adult. The client does not appear to always understand the questions, sometimes answering incorrectly, and stares at the nurse's mouth rather than the nurse's eyes when the nurse is speaking. The client answers in an unusually loud voice. Which of the following impairments should the nurse suspect?
A client has been placed on the drug valproic acid (Depakene). Which would indicate to the nurse that the client is experiencing an adverse reaction to this medication?
The nurse is caring for a client with a permanent tracheostomy who is able to eat. Which is the correct action by the nurse in managing this tube?
The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:
The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should:

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