a nurse is performing pulmonary hygiene for a client who has pneumonia and positions the client on his left side in trendelenburg position from which

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Adult Medical Surgical ATI

1. During pulmonary hygiene for a client with pneumonia, a nurse positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?

A. Lateral segment of the left lower lobe
B. Lateral segment of the right lower lobe
C. Posterior segment of the right middle lobe
D. Posterior segment of the right lower lobe

Correct answer: B

Rationale: When a client is positioned on the left side in Trendelenburg position for pulmonary hygiene, secretions are expected to be mobilized from the lateral segment of the right lower lobe. This positioning helps facilitate drainage and clearance of secretions from this specific area of the lung, aiding in overall pulmonary hygiene and improving ventilation.

2. A client with asthma has developed viral pharyngitis. Which of the following findings should the nurse expect?

A. Petechiae on the chest and abdomen
B. WBC 16,000/mm3
C. Negative throat culture
D. Severe hyperemia of pharyngeal mucosa

Correct answer: C

Rationale: Viral pharyngitis is typically caused by a virus, not bacteria, so a negative throat culture is an expected finding. The presence of petechiae on the chest and abdomen (Choice A) is not a common manifestation of viral pharyngitis. Elevated WBC count (Choice B) is more indicative of a bacterial infection rather than a viral one. Severe hyperemia of the pharyngeal mucosa (Choice D) is a possible finding in pharyngitis but is not specific to viral pharyngitis.

3. How does the pain of a myocardial infarction (MI) differ from stable angina?

A. Accompanied by shortness of breath
B. Feelings of fear or anxiety
C. Lasts about 3-5 minutes
D. Relieved by taking nitroglycerin

Correct answer: A

Rationale: The pain of an MI is often accompanied by shortness of breath and feelings of fear or anxiety. It typically lasts longer than 15 minutes and is not relieved by nitroglycerin. Unlike stable angina, the pain of an MI occurs without a known cause such as exertion.

4. A client had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

A. Poor impulse control
B. Inability to discriminate words and letters
C. Deficits in the right visual field
D. Motor retardation

Correct answer: A

Rationale: A stroke affecting the right cerebral hemisphere can lead to poor impulse control due to the involvement of this area in regulating behavior and inhibiting impulses. Deficits in the right visual field are associated with stroke affecting the left cerebral hemisphere. Inability to discriminate words and letters may be seen in left cerebral hemisphere strokes. Motor retardation may be observed with strokes affecting motor areas in either hemisphere but is not the most specific finding related to a right cerebral hemisphere stroke.

5. Prior to a thoracentesis, what intervention should the nurse complete?

A. Measure oxygen saturation before and after the procedure.
B. Verify that the client has given informed consent.
C. Explain the procedure briefly to the client and their family.
D. Ensure informed consent has been obtained from the client.

Correct answer: D

Rationale: Before a thoracentesis procedure, it is crucial to ensure that the client has given informed consent. This process involves explaining the procedure, its risks, benefits, and alternatives to the client, and obtaining their signature on the consent form. Verifying informed consent is a vital legal and ethical step to protect the client's autonomy and ensure they have made an informed decision about the procedure.