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Which type of joint permits movement in any direction? Pivot Hinge Biaxial Ball-and-socket
Ball-and-socket Ball-and-socket joints permit movement in any direction. Pivot joints permit rotation. Hinge joints allow motion in one plane. Biaxial joints permit gliding movement.
Which hormone is formed from cholesterol? Insulin Cortisol Prolactin Growth hormone
Cortisol All lipid-soluble hormones are synthesized from cholesterol. Cortisol, a lipid-soluble hormone, is secreted by the adrenal cortex. All water-soluble hormones are formed from amino acids. Insulin, prolactin, and growth hormone are water-soluble hormones. Insulin is secreted by the pancreas. Prolactin and growth hormone are also secreted by the pituitary gland.
How is hemophilia A inherited? X-linked recessive trait Y-linked recessive trait X-linked dominant trait Y-linked dominant trait
X-linked recessive trait Hemophilia A is an X-linked recessive trait, not a dominant trait, meaning daughters who have the gene are carriers, and sons with the gene have the condition. The trait is not carried on the Y chromosome.
The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause? Gastritis Hiatal hernia Diverticulosis Bowel obstruction
Bowel obstruction Causes of peritonitis include bowel obstruction, appendicitis, external penetrating wound, or peritoneal dialysis. Gastritis and hiatal hernias do cause gastrointestinal discomfort, but not peritonitis. Inflammation of the diverticular pockets, diverticulitis, is a cause of peritonitis. Diverticulosis is not an active inflammatory process.
How would the nurse explain the purpose of early ambulation to a client who had surgery the previous day? Promote healing of the incision Decrease the incidence of urinary tract infections Allow nursing staff to change the bedding Keep blood from pooling in the legs to prevent clots
Keep blood from pooling in the legs to prevent clots The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis. Protein and vitamin C promote wound healing. Walking is not related to the prevention of urinary tract infections. Although nursing staff do often change the bed when clients are up ambulating, the purpose of early ambulation is prevention of client complications, not making nursing actions more convenient for the staff.
Which finding in a urinalysis indicates a urinary tract infection? Crystals Bilirubin Ketones Leukoesterase
Leukoesterase Leukoesterases are released by white blood cells in response to an infection or inflammation. The presence of this chemical in urine indicates a urinary tract infection. The presence of crystals in the urine indicates that the specimen had been allowed to stand. Presence of bilirubin in the urine indicates anorexia nervosa, diabetic ketoacidosis, and prolonged fasting. The presence of ketones indicates diabetic ketoacidosis.
Which structures are included in the external genitalia of the male anatomy? Select all that apply. One, some, or all responses may be correct. Penis Testes Scrotum Urethra Seminal vesicles
Penis Scrotum The male reproductive system is divided into primary reproductive organs and secondary reproductive organs. Secondary reproductive organs include ducts, sex glands, and external genitalia. The external genitalia consists of the penis and the scrotum. Testes are the primary reproductive organs. The urethra is the duct, and the seminal vesicles are sex glands.
A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen? To prevent dyspnea To prevent cyanosis To increase oxygen concentration to heart cells To increase oxygen tension in the circulating blood
To increase oxygen concentration to heart cells Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells.
A client presents with hemoptysis. The nurse recalls that the clinical manifestation is associated with which disease? Anemia Pneumonia Tuberculosis Leukocytosis
Tuberculosis Hemoptysis is expectoration of blood-stained sputum derived from the lungs, bronchi, or trachea; this is a clinical manifestation of tissue erosion caused by tuberculosis. Anemia does not cause bleeding, but it may be caused by bleeding. Pneumonia causes sputum as a result of inflammation, but the sputum usually is yellow, not bloody. Leukocytosis is increased white blood cells; it does not cause hemoptysis.
Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. Which term would be used when documenting this assessment finding? Fine crackles Adventitious sounds Vesicular breath sounds Diminished breath sounds
Vesicular breath sounds Vesicular breath sounds are expected respiratory sounds heard on auscultation as inspired air enters and leaves alveoli. Fine crackles are faint crackling sounds heard at the end of inspiration; they are associated with pulmonary edema. "Adventitious sounds" is a general term for all abnormal breath sounds. Diminished breath sounds are evidence of a decreased amount of air entering the alveoli; this usually is caused by obstruction or consolidation.
Which hormone has both inhibiting and releasing action? Prolactin Somatostatin Somatotropin Gonadotropin
Prolactin Prolactin secreted by the hypothalamus has both inhibiting and releasing action. Somatostatin inhibits the secretion of growth hormone. Somatotropin and gonadotropin are releasing hormones.
A client diagnosed with acquired immunodeficiency syndrome (AIDS) states, "I'm not worried because they have a cure for AIDS." Which response would the nurse use? "Repeated phlebotomies may be able to rid you of the virus." "You may be cured of AIDS after prolonged pharmacological therapy." "Perhaps you should have worn condoms to prevent contracting the virus." "There is no cure for AIDS, but there are medications that can slow down the virus."
"There is no cure for AIDS, but there are medications that can slow down the virus." Stating, "There is no cure for AIDS, but there are medications that can slow down the virus," is an honest response that corrects the client's misconception about the effectiveness of the current antiviral medications. Phlebotomy is not the treatment used to remove the virus from the client's body. Current pharmacological treatment does not eliminate the virus from the body, but the treatment can slow the progression of the virus. Treatment may even effect a remission (although, the medications are never discontinued), but there is no known cure. Stating, "Perhaps you should have worn condoms to prevent contracting the virus," is a nontherapeutic, judgmental response potentially alienating the client and precipitating feelings of guilt.
When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give? "You developed an infection that requires antibiotics." "This is a highly contagious infection requiring isolation." "An infection you had before beginning treatment has flared up." "Your infection occurred because of exposure to a health care facility. "
"Your infection occurred because of exposure to a health care facility. " A health care-acquired infection is contracted during treatment in a health care facility, such as a hospital or nursing home. Both community-acquired and health care-acquired infections may require antibiotics. Community-acquired and health care-acquired infections may require isolation. An infection that occurred before hospitalization would be called a community-acquired infection.
Which urine specific gravity level is abnormal? 1.006 1.012 1.028 1.041
1.041 The normal specific gravity of urine lies between 1.005 and 1.030. A specific gravity value of 1.041 is higher than the normal range; therefore it's abnormal. The specific gravity values of urine such as 1.006, 1.012, and 1.028 lie in the normal range.
The spouse of a client with pulmonary tuberculosis (TB) received a tuberculin skin test. The nurse examined the skin test and identified an area of induration greater than 10 mm. Which response to this finding would the nurse implement? No further action is required at this time. Additional tests are necessary to determine infection status. Immediately repeat the skin test for confirmation. Results are positive, indicating an active infection.
Additional tests are necessary to determine infection status. The test does not indicate whether TB is dormant or active. However, a client with an induration of 5 mm or greater is considered positive. If there is repeated close contact with a person diagnosed with pulmonary TB or if the client has a disease causing decreased resistance, this requires further diagnostic study, such as chest x-rays and sputum culture. A newly infected client will receive preventive therapy with isoniazid (INH). Isoniazid will be continued for 6 months if chest x-rays are normal, or 12 months if chest x-rays are abnormal. Repeating the skin test is not necessary; the test is considered positive.
Which diagnostic test is used for the direct visualization of ligaments, menisci, and articular surfaces of joints? Arthroscopy Muscle biopsy Ultrasonography Electromyography
Arthroscopy Arthroscopy is a diagnostic test that uses an arthroscope to directly visualize the ligaments, menisci, and articular surfaces of a joint. A muscle biopsy is conducted to diagnose atrophy and inflammation. An ultrasonography is used to view soft tissue disorders, traumatic joint injuries, and osteomyelitis. An electromyography may be performed to evaluate diffuse or localized muscle weakness.
To check a client's carotid pulse, where would the nurse palpate? Below the mandible In the lateral neck region Along the clavicle at the base of the neck At the anterior neck, lateral to the trachea
At the anterior neck, lateral to the trachea The carotid artery is located along the anterior edge of the sternocleidomastoid muscle at the level of the lower margin of the thyroid cartilage. Below the mandible, in the lateral neck region, and along the clavicle at the base of the neck are not the anatomical landmarks for locating the carotid artery.
A client who is receiving peritoneal dialysis reports severe respiratory difficulty. Which immediate action would the nurse implement? Auscultate the lungs. Obtain arterial blood gases. Notify the health care provider. Apply pressure to the abdomen.
Auscultate the lungs. Always assess the client first to determine if the lung sounds are indicative of fluid overload. When respiratory distress occurs, possibly from pressure of the dialysate on the diaphragm, respiratory status and vital signs should be assessed. The health care provider should be notified and arterial blood gases should be obtained after immediate action is taken. Never apply pressure to the abdomen, as that could worsen the respiratory status.
Which surgery will a client undergo if pituitary gland must be removed? Mastectomy Prostatectomy Thyroidectomy Hypophysectomy
Hypophysectomy A hypophysectomy is the surgical removal of the pituitary gland or its tumor. A mastectomy is the surgical removal of breast tissue. A prostatectomy is the surgical removal of the prostate gland. A thyroidectomy is the surgical removal of the thyroid gland.
Which product would the nurse instruct intravenous drug users (IDUs) to use for cleaning of needles and syringes between uses? Bleach Hot water Ammonia Rubbing alcohol
Bleach IDUs should be instructed to fill syringes with household bleach and shake the syringe for 30 to 60 seconds. Hot water, ammonia, or rubbing alcohol is not used to disinfect used syringes.
Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins? Medication eruption Atopic dermatitis Contact dermatitis Nonspecific eczematous dermatitis
Contact dermatitis In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins. In medication eruption, bright-red erythematosus macules and papules are seen. In atopic dermatitis, lichenification with scaling and excoriation is observed. Lichenification with weeping papules and macules is seen in nonspecific eczematous dermatitis.
Which information would the nurse provide a client with a new colostomy about managing the appliance? Use stoma powder for fungal rashes. Wash peristomal area with soap first. Measure stoma once a month for size. Cut opening 1/8- to 1/16-inch larger than stoma.
Cut opening 1/8- to 1/16-inch larger than stoma. The first 6 to 8 weeks after surgery as inflammation subsides, the stoma will shrink in size. Therefore it is important to measure the stoma once a week and cut the opening 1/8- to 1/16-inch larger than the stoma so the wafer does not cut into the stoma. Antifungal cream or powder is used for fungal rashes. Soap should not be used on the peristomal area to prevent drying, which can lead to infection.
Which diagnostic procedure is used to detect muscle weakness? Arthroscopy Radiography Myelography Electromyography
Electromyography Electromyography is performed to detect diffuse or localized muscle weakness by determining the electric potential generated in an individual. Arthroscopy is used for the direct visualization of ligaments, menisci, and articular surfaces of a joint. A radiography is performed to detect bone density, alignment, swelling, and intactness of a joint. A myelography is performed to visualize the vertebral column, intervertebral discs, spinal nerve roots, and blood vessels.
The nurse is educating a couple concerning the process of fertilization. Which hormone would the nurse explain as stimulating the release of estrogen and progesterone after fertilization? Inhibin Testosterone Follicle-stimulating hormone (FSH) Human chorionic gonadotropin (hCG)
Human chorionic gonadotropin (hCG) After fertilization, human chorionic gonadotropin (hCG) stimulates the corpus luteum to produce estrogen and progesterone. Inhibin is a hormone produced by the ovarian follicles; it inhibits the secretion of FSH and gonadotropin-releasing hormone. Testosterone does not affect the release of estrogen and progesterone. Follicle-stimulating hormone (FSH) stimulates the growth and maturity of the ovarian follicle necessary for ovulation.
Which of the following would the client with palpitations from premature heartbeats be taught to avoid? Bananas Tomatoes Energy drinks Green leafy vegetables
Energy drinks Energy drinks should be avoided in the client with palpitations from premature heartbeats because they contain caffeine and can increase ectopic beats. Bananas and tomatoes are high in potassium and are not a contraindication for the client with ectopic beats. Dark green leafy vegetables should be avoided by the client taking warfarin, because the vitamin K content counteracts the medication's therapeutic blood thinning.
Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing? Glottis Paranasal sinus Palatine tonsils Eustachian tubes
Eustachian tubes The Eustachian tubes connect the nasopharynx to the middle ears; these tubes open during swallowing to equalize pressure within the middle ear. The glottis is the opening between true vocal cords. The paranasal sinuses are air-filled cavities within the bones that surround the nasal passages. Palatine tonsils are a part of the immune system and are located on the sides of the oropharynx. These tonsils protect against invading organisms.
What would the presence of ketones in the urine of a client indicate? Cystitis Heart failure Urinary calculi Fat metabolism
Fat metabolism The body of a client, who is ingesting fewer calories than are needed for maintenance, produces ketones from fat metabolism as an alternate source of fuel for muscles and organs. Increased red blood cells in the urine indicate cystitis. Increased specific gravity of the urine indicates heart failure. The presence of casts in the urine indicates urinary calculi.
Which type of shock is associated with a ruptured abdominal aneurysm? Vasogenic shock Neurogenic shock Cardiogenic shock Hypovolemic shock
Hypovolemic shock When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel. Vasogenic shock results from humoral or toxic substances acting directly on the blood vessels, causing vasodilation. Neurogenic shock results from decreased neuromuscular tone, causing decreased vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.
Which antibody forms first, after exposure to an antigen? Immunoglobulin A (IgA) Immunoglobulin E (IgE) Immunoglobulin G (IgG) Immunoglobulin M (IgM)
Immunoglobulin M (IgM) IgM is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily expressed on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms.
Which condition is an example of a bacterial infection? Impetigo Candidiasis Plantar warts Verruca vulgaris
Impetigo Impetigo is the bacterial infection of skin caused by group A β-hemolytic streptococci or Staphylococcus aureus. Candidiasis is the fungal infection caused by Candida albicans. Plantar warts and verruca vulgaris are viral infections caused by the human papilloma virus.
Which clinical manifestation is associated with cellulitis? Lymphadenopathy Occasional papules Vesicles that evolve into pustules Isolated erythematous pustules
Lymphadenopathy Cellulitis is accompanied by lymphadenopathy. Occasional papules are present in folliculitis. Herpes simplex viral infections evolve the vesicles into pustules. Isolated erythematous pustules occur in folliculitis bacterial infections.
Which criteria would the nurse consider when determining if an infection is a health care-associated infection? Originated primarily from an exogenous source Is associated with a medication-resistant microorganism Occurred in conjunction with treatment for an illness Still has the infection despite completing the prescribed therapy
Occurred in conjunction with treatment for an illness Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care-associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus. Association with a medication-resistant microorganism is not a criterion for identifying a health care-associated infection. A health care-associated infection may or may not be caused by a medication-resistant microorganism. Still having the infection despite completing the prescribed therapy is not a criterion for identifying a health care-associated infection.
How would the nurse document a drop in blood pressure when a client moves rapidly from a lying to a standing position? Malignant hypotension Orthostatic dehydration Orthostatic hypotension Vasomotor instability
Orthostatic hypotension Orthostatic hypotension specifically refers to an abnormally low blood pressure that occurs when an individual assumes a standing position. Orthostatic hypotension is also known as postural hypotension. It may be a result of internal bleeding, fluid depletion, or loss of neurovascular control preventing vasoconstriction from regulating blood pressure. Malignant hypotension and orthostatic dehydration are inaccurate terms that are not used. Vasomotor instability occurs during menopause and results in hot flashes and night sweats.
Which condition is characterized by infection of a client's bone or bone marrow? Osteomalacia Osteomyelitis Herniated disc Spinal stenosis
Osteomyelitis Osteomyelitis is infection of bone or bone marrow. Osteomalacia is a condition characterized by softening of bones due to calcium or vitamin D deficiency. Herniated disc is caused by structural damage of the intervertebral discs in which the nucleus pulposus seeps through a torn or stretched annulus. Spinal stenosis is narrowing of the spinal canal.
Which hormone is released from the posterior pituitary gland? Oxytocin Prolactin Growth hormone Luteinizing hormone
Oxytocin Oxytocin is released from the posterior pituitary gland, which acts on the uterus and mammary glands. Prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland.
After reviewing information about oxygenation for 4 clients with chronic obstruction pulmonary disease, which client will the nurse plan to teach about use of home long-term continuous oxygen therapy? Partial pressure of oxygen (PaO 2) of 72; peripheral capillary oxygen saturation (SpO 2) of 96 PaO 2 of 60; SpO 2 of 90 PaO 2 of 55; SpO 2 of 88 PaO 2 of 70; SpO 2 of 92
PaO 2 of 55; SpO 2 of 88 A PaO 2 of 55 and SpO 2 of 88 indicate hypoxemia and that long-term oxygen therapy is needed. The values PaO 2 72 and SpO 2 96 indicate adequate oxygenation. The values PaO 2 60 and SpO 2 90 are adequate and the client would not require oxygen therapy. The values PaO 2 70 and SpO 2 92 are adequate and do not indicate a need for oxygen therapy.
Which physical assessment maneuver is the nurse performing when placing the nurse's left hand under on the client's right lower back between the rib cage and the iliac crest? Palpation Inspection Percussion Auscultation
Palpation The physical assessment involves inspection, palpation, percussion, and auscultation. During palpation of the right kidney, the nurse places the left hand behind and supports the client's right side between the ribcage and the iliac crest. During an inspection, the nurse assesses the client for changes in skin, abdomen, weight, face, and extremities. During percussion, the nurse strikes the fist of one hand against the dorsal surface of the other hand, which is placed flat along the post costovertebral angle (CVA) margin. While performing auscultation, the nurse uses the bell of the stethoscope over both CVAs and in the upper abdominal quadrants.
Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor? Proteus Bacteroides Pseudomonas Staphylococcus
Pseudomonas The purulent exudates of greenish-blue pus with a fruity odor signifies colonization with Pseudomonas. Proteus colonization causes pus with a fishy odor. The colonization of Bacteroides causes brownish pus with a fecal odor. Staphylococcus colonization results in purulent exudate of creamy yellow pus.
Which action is promoted by vasopressin? Sodium reabsorption Reabsorption of water Tubular secretion of sodium Red blood cell production
Reabsorption of water Vasopressin is also known as an antidiuretic hormone. It helps in the reabsorption of water into the capillaries. Aldosterone promotes sodium reabsorption. Natriuretic hormones promote tubular secretion of sodium. Erythropoietin stimulates bone marrow to make red blood cells.
The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select all that apply. One, some, or all responses may be correct. Diarrhea Bradycardia Rebound tenderness Diminished bowel sounds Rigid, boardlike abdomen
Rebound tenderness Diminished bowel sounds Rigid, boardlike abdomen Classic signs of peritonitis include abdominal rebound tenderness, diminished or absent bowel sounds, and a rigid, boardlike abdomen. The client will experience constipation, not diarrhea. The heart rate will be tachycardic.
Which mechanism of action for wet-to-damp saline-moistened gauze for wound debridement is correct? Promoting the dilution of viscous exudate Removing the necrotic tissue mechanically Causing a breakdown of the denatured protein of the eschar Promoting the spontaneous separation of necrotic tissue
Removing the necrotic tissue mechanically Wet-to-damp saline-moistened gauze mechanically removes the necrotic tissue. The dilution of viscous exudates is promoted through the continuous wet-gauze technique. Topical enzyme preparations cause a breakdown of the denatured protein of the eschar. Moisture-retentive dressings promote the spontaneous separation of necrotic tissue through autolysis.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco 2 of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO 2, and the acceptable range of arterial Pco 2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO 3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.
The nurse is preparing to insert a nasogastric (NG) tube for a client to allow continuous suction. Which tube would the nurse select? Levin Dobhoff Salem sump Gastrostomy
Salem sump A Salem sump tube has a vent that prevents the suction from pulling at the gastrointestinal mucosa and should be used for clients requiring continuous suction. A Levin tube does not have a vent and should be used strictly for intermittent suction. A Dobhoff is a nasointestinal tube used for feeding, not suction. A gastrostomy tube is surgically placed for feeding.
A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats per minute. The rhythm is regular. Which would the nurse conclude that the client is experiencing? Atrial fibrillation Sinus tachycardia Ventricular fibrillation First-degree atrioventricular block
Sinus tachycardia The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillation causes an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.
Which stage of the human immunodeficiency virus (HIV) would a client with a CD4+ T cell count of 325 cells/mm 3 be classified? Stage 1 Stage 2 Stage 3 Stage 4
Stage 2 Stage 2 describes a client with a CD4+ T cell count between 200 and 499 cells/mm 3. Stage 1 describes a client with a CD4+ T cell count of greater than 500 cells/mm 3. Stage 3 describes a client with a CD4+ T cell count of less than 200 cells/mm 3. Stage 4 describes a client with a confirmed HIV infection but no information regarding CD4+ T cell counts is available.
Which risk factor for head and neck cancer would the nurse assess for in a client with a persistent, nagging cough? Select all that apply. One, some, or all responses may be correct. Type of employment Presence of ear pain History of tobacco use Oral hygiene practices Amount of alcohol intake
Type of employment Presence of ear pain History of tobacco use Oral hygiene practices Amount of alcohol intake There are several risk factors for head and neck cancers. The nurse would obtain information about the client's employment to determine possible chemical or environmental exposures that can increase the risk for head and neck cancers. The symptom of ear pain along with a nagging cough can indicate head or neck cancer. The use of tobacco and alcohol is a major risk factor for head and neck cancer. Poor oral hygiene is another risk factor the nurse can assess for.
How would the nurse position a client to practice supraglottic swallowing after tracheostomy? In bed Upright Lying down Position of comfort
Upright The safest position for supraglottic swallowing is sitting upright. Clients should be out of bed, if possible. Clients are at risk for aspiration if swallowing while supine. Comfort is always a goal of positioning clients, but upright is the priority for safe swallowing.
How would the nurse position a client with epistaxis? Supine Side-lying Upright leaning forward Sitting with the head tipped backward
Upright leaning forward A client with a nosebleed should be positioned upright leaning forward to prevent aspiration and decrease blood flow to the nose. The supine position increases the risk for aspiration or swallowing blood. The side-lying position will increase blood flow to the nose more than sitting upright and may increase aspiration risk. Having the head tipped backward increases the risk for aspiration or swallowing blood.
When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding? Adventitious sounds Fine crackling sounds Vesicular breath sounds Diminished breath sounds
Vesicular breath sounds Vesicular breath sounds are normal respiratory sounds heard on auscultation as inspired air enters and leaves the alveoli. "Adventitious" is the general term for all abnormal breath sounds. Crackles heard at the end of an inspiration are associated with fluid in the alveoli. Diminished breath sounds are evidence of a reduction in the amount of air entering the alveoli; this usually is caused by obstruction or consolidation.
