What is the proper hand position when performing chest vibration?

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Question 1 of 9

What is the proper hand position when performing chest vibration?

Correct Answer: B

Rationale: The correct hand position for performing chest vibration is to spread the fingers. This allows for a larger surface area of contact with the chest, promoting effective transmission of vibrations to loosen chest secretions. Flattening the hands would reduce the effectiveness of the vibrations by limiting contact area. Cupping the hands creates a smaller contact area and may concentrate the pressure too much in one spot, potentially causing discomfort or injury. Therefore, spreading the fingers is the optimal hand position for chest vibration technique.

Question 2 of 9

A middle-aged woman reports irregular menses for six months. The nurse should assess for symptoms of:

Correct Answer: C

Rationale: The correct answer is C: perimenopause. Perimenopause is the transitional period before menopause when a woman's body begins to produce less estrogen. This can lead to irregular menstrual cycles and other symptoms such as hot flashes, night sweats, and mood changes. Assessing for symptoms of perimenopause in a woman reporting irregular menses for six months is appropriate as it aligns with the timing and characteristics of this phase. Explanation for incorrect choices: A: Climacteric refers to the period of menopausal transition and is not specific to the symptoms mentioned in the scenario. B: Menopause is the cessation of menstrual periods for 12 consecutive months and is not typically associated with irregular menses. D: Postmenopause is the period after menopause has been established for at least 12 months and irregular menses would not be expected during this phase.

Question 3 of 9

What symptoms should a nurse assess for in a woman experiencing irregular menses over the past six months?

Correct Answer: C

Rationale: The correct answer is C: perimenopause. Perimenopause is the transitional phase leading to menopause, characterized by irregular menstrual cycles. Climacteric refers to the period of reproductive senescence, not just irregular menses. Menopause is the cessation of menstruation for 12 consecutive months. Postmenopause is the period after menopause, not characterized by irregular menses. Assessing for symptoms of perimenopause in a woman with irregular menses over the past six months is important to understand the hormonal changes and potential menopausal symptoms she may be experiencing.

Question 4 of 9

What should the nurse do when a client develops a deep vein thrombosis (DVT)?

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants help prevent the blood clot from getting larger and reduce the risk of it breaking loose and causing a pulmonary embolism. Other choices are incorrect because B: Monitoring vital signs alone does not treat the DVT, C: Providing bed rest can increase the risk of complications like pulmonary embolism, and D: Administering fibrinolytics is not the first-line treatment for DVT.

Question 5 of 9

What is the proper hand position when performing chest vibration?

Correct Answer: B

Rationale: The correct hand position for performing chest vibration is to spread the fingers. This allows for a larger surface area of contact with the chest, promoting effective transmission of vibrations to loosen chest secretions. Flattening the hands would reduce the effectiveness of the vibrations by limiting contact area. Cupping the hands creates a smaller contact area and may concentrate the pressure too much in one spot, potentially causing discomfort or injury. Therefore, spreading the fingers is the optimal hand position for chest vibration technique.

Question 6 of 9

What should be the nurse's first action when a client develops signs of hypovolemic shock?

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In hypovolemic shock, there is a significant decrease in blood volume leading to inadequate perfusion of tissues. Administering IV fluids helps to restore circulating volume and improve tissue perfusion, which is crucial in managing hypovolemic shock. Elevating the client's legs (B) may be beneficial in other types of shock but not specifically in hypovolemic shock. Administering pain relief (C) and corticosteroids (D) are not the priority in hypovolemic shock as they do not address the underlying issue of decreased blood volume and tissue perfusion.

Question 7 of 9

How do nurses facilitate the achievement of high-level wellness with a client?

Correct Answer: C

Rationale: The correct answer is C because promoting health in the client is essential in achieving high-level wellness. Nurses play a crucial role in educating, empowering, and supporting clients in making healthy lifestyle choices. By promoting health, nurses help clients prevent illness, maintain optimal well-being, and improve their overall quality of life. Encouraging appointment attendance (choice A) is important but not solely focused on wellness promotion. Providing information on alternative treatments (choice B) is valuable but may not directly contribute to high-level wellness. Providing good client care (choice D) is a fundamental nursing responsibility, but it does not specifically address the promotion of health and wellness.

Question 8 of 9

Which positions are appropriate for clients with dumping syndrome and GERD after meals?

Correct Answer: B

Rationale: Rationale: 1. GERD: Lying down after eating can worsen symptoms due to acid reflux. Sitting up helps prevent acid reflux. 2. Dumping Syndrome: Lying down can exacerbate symptoms like nausea and dizziness. Sitting up aids in digestion. 3. Choice B recommends lying down 1 hour after eating for Dumping Syndrome and sitting up at least 30 minutes after eating for GERD, which aligns with the management of both conditions. Summary: - Choice A is incorrect as lying flat after meals worsens GERD and Dumping Syndrome symptoms. - Choice C is incorrect as sitting up only after meals does not address the specific needs of GERD and Dumping Syndrome. - Choice D is incorrect as lying down after meals is not recommended for either condition.

Question 9 of 9

What is the priority action for a client with a suspected myocardial infarction?

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the priority action for a client with a suspected myocardial infarction as it helps dilate coronary arteries, improving blood flow to the heart muscle. This helps reduce chest pain and minimize myocardial damage. Administering fluids (B) may be necessary but not the priority. Placing the client in a sitting position (C) could worsen symptoms. Administering aspirin (D) is important but not as immediate as nitroglycerin for acute pain relief.

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