To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

Teach the client breathing exercises.

Establish a regular bladder routine.

Perform chest physiotherapy.

Encourage use of incentive spirometer.

Initiate passive range of motion exercises.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A reason: Teaching the client breathing exercises can help improve lung function, reduce mucus accumulation, and prevent atelectasis and pneumonia. Breathing exercises can include pursed-lip breathing, diaphragmatic breathing, and coughing techniques.

Choice B reason: Establishing a regular bladder routine is not directly related to pulmonary complications. However, it can help prevent urinary tract infections, bladder distension, and incontinence, which are common problems for clients with ALS.

Choice C reason: Performing chest physiotherapy can help mobilize secretions, improve ventilation, and prevent respiratory infections. Chest physiotherapy can include percussion, vibration, and postural drainage.

Choice D reason: Encouraging use of incentive spirometer can help increase lung expansion, improve oxygenation, and prevent alveolar collapse. Incentive spirometer is a device that measures the amount of air the client can inhale and exhale.

Choice E reason: Initiating passive range of motion exercises can help maintain joint mobility, prevent contractures, and improve circulation. Passive range of motion exercises are performed by the nurse or a caregiver who moves the client's limbs through their full range of motion.

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Correct Answer is A

Explanation

Choice A reason: Whole milk and ice cream are high in fat, which can trigger the inflammation of the gallbladder (cholecystitis) and the formation of gallstones. The client should avoid foods that are high in fat, such as fried foods, cheese, butter, cream, and fatty meats.

Choice B reason: Citrus fruit and melon with a salt substitute are not a problem for a client with cholecystitis, unless they have other conditions that require dietary modifications, such as diabetes or kidney disease. The client should eat a balanced diet that includes fruits, vegetables, grains, and lean proteins.

Choice C reason: Pasta with herbal butter and no meat sauce is also acceptable for a client with cholecystitis, as long as the butter is used sparingly and the pasta is not cooked with oil or cheese. The client should limit the intake of refined carbohydrates, such as white bread, rice, and sugar, and choose whole grains instead.

Choice D reason: Canned vegetables with additional table salt are not recommended for a client with cholecystitis, because they are high in sodium, which can increase the risk of fluid retention and hypertension. The client should reduce the intake of salt and processed foods, such as canned soups, sauces, and snacks, and use herbs and spices to flavor the food.

A. Log roll the client and place adult disposable briefs beneath the client. B. Maintain traction while the client uses a urinal. C. Release the traction so the client can use a bedpan. D. Insert an indwelling urinary catheter preoperatively.

Correct Answer is B

Explanation

Choice A reason: Log rolling the client and placing adult disposable briefs beneath the client is not a correct intervention, as it can cause displacement or misalignment of the fracture, which can lead to complications, such as delayed healing, nerve damage, or infection. Log rolling is a technique that involves moving the client as a unit, without twisting or bending the spine. Adult disposable briefs are absorbent pads that can be worn to manage urinary incontinence.

Choice B reason: Maintaining traction while the client uses a urinal is the correct intervention, as it can prevent the disruption of the fracture stabilization and allow the client to void comfortably and safely. Traction is a force that is applied to the fractured bone to reduce, align, and immobilize it. A urinal is a container that can be used to collect urine from the client, without requiring the client to get out of bed or change position.

Choice C reason: Releasing the traction so the client can use a bedpan is not a correct intervention, as it can compromise the fracture reduction and alignment, and cause pain and discomfort to the client. A bedpan is a shallow vessel that can be used to collect urine or feces from the client, by placing it under the client's buttocks. Releasing the traction can also increase the risk of bleeding, swelling, or infection.

Choice D reason: Inserting an indwelling urinary catheter preoperatively is not a necessary intervention, unless the client has urinary retention, obstruction, or infection. An indwelling urinary catheter is a tube that is inserted into the bladder through the urethra, and attached to a drainage bag. An indwelling urinary catheter can pose risks of trauma, infection, or bladder spasms, and should be avoided unless indicated.

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To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

Correct Answer is A

Explanation

A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?

Correct Answer is B

Explanation

Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing’s syndrome?

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

A client taking antibiotics for three days to treat a Streptococcal throat infection returns to the clinic reporting a feel itchy rash across the chest and arms. The nurse auscultates pulmonary wheezing and an elevated heart rate. Which action should the nurse implement?

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?