AND 100% CORRECT WELL DETAILED
ANSWERS|LATEST UPDATE!!!
2. You're providing discharge teaching to a patient who was admitted with asthma. You
discussed the early warning signs of an asthma attack and ask the patient to list some of
them. Select all the correct early warning signs verbalized by the patient:
A. Easily fatigued with physical activity
B. Reduced peak flow meter reading
C. Chest retractions
D. Cyanosis
E. Wheezing with activity
F. Nighttime coughing
G. No relief with short-acting bronchodilator inhaler - ANSWER A,B,E,F
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress.
Which type of adventitious lung sounds should the nurse expect to hear when performing a
respiratory assessment on this client?
A. Stridor
B. Crackles
C. Wheezes
D. Diminished - ANSWER C. Wheezes
Rational: asthma is a respiratory disorder characterized by recurrent episodes of dyspnea,
constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical
sounds heard when air passes through an obstructive or narrow lumen of a respiratory
passageway. Stridor is a harsh sound noted with an upper airway obstruction and often
signals a life-threatening emergency. Crackles are produced by air passing over retained
1
,airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung
sounds are heard over lung tissue were poor oxygen exchange is occurring.
The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the
client in which position for insertion?
A. Right side
B. Low-Fowler's
C. High-Fowler's
D. Supine with the head flat - ANSWER C. High-Fowler's
Rationale: during insertion of an NG tube, the client is placed in a sitting or high Fowlers
position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the
client should vomit.
A client is being prepared for a thoracentesis. The nurse should assist the client to which
position for the procedure?
A. Lying in bed on the affected side
B. Lying in bed on the unaffected side
C. Sims position with the head of the bed flat
D. Prone with the head turned to the side and supported by pillow - ANSWER B. Lying
in bed on the unaffected side
Rationale: to facilitate removal of fluid from the chest, the client is positioned sitting at the
edge of the bed leaning over the bedside table, with feet supported on a stool; or lying in
bed on the unaffected side with the head of the bed elevated 30 to 45°
The nurse creates a plan of care for a patient with deep vein thrombosis. Which client
position or activity in the plans should be included?
2
, A. Out of bed activities as desired
B. Bedrest with the affected extremity kept flat
C. Bedrest with elevation of the affected extremity
D. Bedrest with the affected extremity in a dependent position - ANSWER C. Bedrest
with elevation of the affected extremity
Rationale: for the client with deep vein thrombosis, elevation of the affected leg facilitates
blood flow by the force of gravity and decreases venous pressure, which intern relieves
Edema and pain.
The nurse is caring for a client who was one day post operative for a total hip replacement.
Which is the best position in which the nurse should place the client?
A. Head elevated lying on the operative side
B. On the non-operative side with legs abducted
C. Side lying with the affected leg internally rotated
D. Side lying with the affected leg externally rotated - ANSWER B. On the non-
operative side with legs abducted
Rationale: positioning after a total hip replacement depends on the surgical techniques
used, the method of implantation, the prosthesis, and the primary healthcare providers
preference. Abduction is maintained when the client is in a supine position or positioned on
the non-operative side. Internal and X ternal rotation, adduction, or lying on the operative
side is avoided to prevent displacement of the prosthesis
The nurse is administering a cleansing enema to a client with a fecal impaction. Before
administering the enema, the nurse should place the client in which position?
A. Left Sims position
B. Right Sims position
3
ANSWERS|LATEST UPDATE!!!
2. You're providing discharge teaching to a patient who was admitted with asthma. You
discussed the early warning signs of an asthma attack and ask the patient to list some of
them. Select all the correct early warning signs verbalized by the patient:
A. Easily fatigued with physical activity
B. Reduced peak flow meter reading
C. Chest retractions
D. Cyanosis
E. Wheezing with activity
F. Nighttime coughing
G. No relief with short-acting bronchodilator inhaler - ANSWER A,B,E,F
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress.
Which type of adventitious lung sounds should the nurse expect to hear when performing a
respiratory assessment on this client?
A. Stridor
B. Crackles
C. Wheezes
D. Diminished - ANSWER C. Wheezes
Rational: asthma is a respiratory disorder characterized by recurrent episodes of dyspnea,
constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical
sounds heard when air passes through an obstructive or narrow lumen of a respiratory
passageway. Stridor is a harsh sound noted with an upper airway obstruction and often
signals a life-threatening emergency. Crackles are produced by air passing over retained
1
,airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung
sounds are heard over lung tissue were poor oxygen exchange is occurring.
The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the
client in which position for insertion?
A. Right side
B. Low-Fowler's
C. High-Fowler's
D. Supine with the head flat - ANSWER C. High-Fowler's
Rationale: during insertion of an NG tube, the client is placed in a sitting or high Fowlers
position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the
client should vomit.
A client is being prepared for a thoracentesis. The nurse should assist the client to which
position for the procedure?
A. Lying in bed on the affected side
B. Lying in bed on the unaffected side
C. Sims position with the head of the bed flat
D. Prone with the head turned to the side and supported by pillow - ANSWER B. Lying
in bed on the unaffected side
Rationale: to facilitate removal of fluid from the chest, the client is positioned sitting at the
edge of the bed leaning over the bedside table, with feet supported on a stool; or lying in
bed on the unaffected side with the head of the bed elevated 30 to 45°
The nurse creates a plan of care for a patient with deep vein thrombosis. Which client
position or activity in the plans should be included?
2
, A. Out of bed activities as desired
B. Bedrest with the affected extremity kept flat
C. Bedrest with elevation of the affected extremity
D. Bedrest with the affected extremity in a dependent position - ANSWER C. Bedrest
with elevation of the affected extremity
Rationale: for the client with deep vein thrombosis, elevation of the affected leg facilitates
blood flow by the force of gravity and decreases venous pressure, which intern relieves
Edema and pain.
The nurse is caring for a client who was one day post operative for a total hip replacement.
Which is the best position in which the nurse should place the client?
A. Head elevated lying on the operative side
B. On the non-operative side with legs abducted
C. Side lying with the affected leg internally rotated
D. Side lying with the affected leg externally rotated - ANSWER B. On the non-
operative side with legs abducted
Rationale: positioning after a total hip replacement depends on the surgical techniques
used, the method of implantation, the prosthesis, and the primary healthcare providers
preference. Abduction is maintained when the client is in a supine position or positioned on
the non-operative side. Internal and X ternal rotation, adduction, or lying on the operative
side is avoided to prevent displacement of the prosthesis
The nurse is administering a cleansing enema to a client with a fecal impaction. Before
administering the enema, the nurse should place the client in which position?
A. Left Sims position
B. Right Sims position
3
