EAQ #4 Nurs 220

A 6-year-old child with acute spasmodic bronchitis who is receiving humidified air removes the mask, and while bathing the child the nurse notes increasing respiratory distress. What is the most appropriate nursing intervention?

1. Stopping the bath and replacing the mask.

A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend?

1. Apple

Which nursing interventions would be beneficial for providing safe oxygen therapy? Select all that apply.

1. Check tubing for kinks. 3. Post "no smoking" signs in the clients' rooms.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration?

1. Elevate the head of the bed between 30 and 45 degrees.

A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates, and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse assess the infant?

1. Tachycardia

As the nurse is teaching a child's parents about celiac disease, the mother sighs and says, "My neighbor told me that I'll only need to monitor the diet until our child is 8 years old. I'm so relieved. You know how kids are about eating!" On what fact should the nurse's response be based?

1. The basic defect of celiac disease is lifelong.

A postoperative client is being weaned from mechanical ventilation. What is the most important factor for the nurse to consider when organizing activities?

1. Remain with the client to assess responses.

The parents of a preschooler tell the nurse that they try to inculcate good eating habits by asking the child to be at the table until the "plate is clean." What condition is the child at risk for?

4. Poor eating habits

When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client chooses which breakfast cereal?

4. Shredded Wheat

A slightly overweight client is to be discharged from the hospital after a cholecystectomy. What is most important for the nurse to include in teaching the client about nutrition?

2. Explaining that fatty foods may not be tolerated for several weeks.

The nurse is administering lactulose to a client with a history of cirrhosis of the liver. The client asks the nurse why this medication is needed because the client is not constipated. How will the nurse respond?

3. "This medication helps you lower the high ammonia level caused by your liver disease."

A nurse teaches a client how to perform diaphragmatic breathing. Which instruction should the nurse provide?

3. Expand the abdomen in inhalation.

A client is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning?

3. Green vegetables

After abdominal surgery, a goal is to have the client achieve alveolar expansion. The nurse determines that this goal is most effectively achieved by what method?

3. Incentive spirometry

A nurse is caring for a client who just had surgery for a parotid tumor. Which nursing intervention is the priority in the immediate postoperative period?

3. Keeping the client's respiratory passages patent.

An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis. The client states that a roommate at the extended care facility where the client resides sleeps a lot, coughs a great deal, and sometimes spits up blood. What is the primary reason that the nurse pursues more information about the roommate?

3. Older adults with chronic illness are affected adversely by tuberculosis.

What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis?

3. Placing a tracheostomy unit by the bedside.

The nurse is teaching a client about the prescribed diet after a Whipple procedure for cancer of the pancreas. Which statement should the nurse include in the dietary teaching?

4. "Low-fat meals should be eaten to prevent interference with your fat digestion mechanism."

A client on a 2-gram sodium diet states, "I never add salt to my food when I cook. I just need help selecting low-sodium foods." After receiving dietary education, the client creates sample menus. Which meal selection will cause the nurse to intervene?

4. Cottage cheese, crackers, relish dish (celery, olives, sweet pickles).

A client with chronic obstructive pulmonary disease has increased hemoglobin and hematocrit levels. How should the nurse interpret these findings?

4. Increased erythrocyte production as a result of chronic hypoxia.