Q46- The correct answer is 2 . 1) To prevent injury, the bed needs to be positioned at the nurse's elbows. 2) CORRECT – When moving a client up in bed who weighs 220 lbs and can provide minimal assistance, the nurse must use a friction-reducing device and an additional three individuals to assist. This will help prevent injury. 3) To prevent injury when moving a client up in bed who weighs 220 lbs, a friction-reducing device should be used along with four individuals. 4) If the client is able to reposition without assistance, the bed needs to be placed flat or in a reverse Trendelenburg's position, not Trendenlenburg's position. Q47- The correct answer is 1 . 1) CORRECT - Decreasing fluid intake should reduce the episodes of nocturia, which interrupts sleep. 2) Caffeine should be stopped by late afternoon to decrease its effect on sleep.
3) Maintaining a regular bedtime and wake-time routine will help reduce insomnia. 4) Exercise should be avoided before bedtime due to the stimulation effect. Q48- The correct answer is 1, 2, 3 . 1) CORRECT — IMRT causes fatigue; therefore, the nurse will include this side effect in the teaching session. 2) CORRECT — Radiation directly to the esophagus likely will cause esophageal irritation; therefore, the nurse will include this side effect in the teaching session. 3) CORRECT — Radiation to the esophageal area likely will cause irritation and subsequent hoarseness; therefore, the nurse will include this side effect in the teaching session. 4) The bladder and urethera would not be involved in IMRT for throat cancer. 5) With IMRT, high doses of radiation delivered to the tumor spare adjacent healthy structures, such as the sternum. Therefore, bone marrow suppression is not anticipated. Q49- The correct answer is 1, 2 . 1) CORRECT - A PaO 2 of 88 mm Hg is within normal range of 85 to 95 mm Hg and indicates improved oxygenation. Formoterol is a long-acting bronchodilator. 2) CORRECT—Improvement in cognitive status (alert and oriented to person, place, time, and situation) indicates improved oxygenation. 3) Weight loss is caused by COPD. It is not an effect of formoterol. 4) A diagnosis of COPD results in the high PaCO 2 level of 52 mm Hg, which is significantly elevated above normal range of 35 to 45 mm Hg. This is not a therapeutic effect of formoterol. 5) A diagnosis of COPD results in decreased pH below normal range of 7.35 to 7.45, which is indicative of respiratory acidosis due to air-trapping. This is not a therapeutic effect of formoterol. Q50- The correct answer is 1 . 1) CORRECT — The nurse’s signature only states that the client signing the form was the person listed as having the procedure. 2) The criteria for the client giving consent include that it is done without pressure or coercion, but that is not what the nurse is witnessing. 3) The criteria for the client giving consent include that the client is awake, alert, and not under the influence of narcotic medication, but this is not what the nurse is witnessing.
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- Winter '19
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