Nokea
The nurse is preparing the client for a liver biopsy. Which statement by the client indicates a need for further instruction regarding the procedure?
- A. I can resume strenuous activity in 2 to 3 days.
- B. I will have to lay on my right side after the procedure.
- C. I will have a small bandage instead of stitches afterward.
- D. My right shoulder may begin to hurt as the anesthesia wears off.
- E. I may have a small amount of pain or discomfort during the procedure.
Correct Answer: A
Rationale: Strenuous activity should be avoided for 1-2 weeks post-liver biopsy to prevent bleeding, indicating a need for further teaching.
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A student nurse is discussing fluid overload with the staff nurse. Which statement by the student nurse indicates a need for further explanation by the staff nurse?
- A. Pitting edema is the best indicator of fluid overload.
- B. The client may have distended veins in the hands and neck.
- C. I may hear moist crackles in the lungs during my respiratory assessment.
- D. The client may need drug therapy and sodium restriction to treat the overload.
Correct Answer: A
Rationale: Pitting edema is one indicator, but not the best, as fluid overload is assessed holistically (e.g., crackles, distended veins). Other statements are accurate.
The nurse is caring for a homeless client brought to the emergency department with a diagnosis of heat stroke. Which key features of heat stroke would the nurse expect to note upon assessment? Select all that apply.
- A. a body temperature of 104.2°F
- B. heart rate of 116 and blood pressure of 78/52
- C. heart rate of 49 and blood pressure of 152/90
- D. heart rate of 120 and respiratory rate of 9 breaths per minute
- E. blood pressure of 82/48 and respiratory rate of 26 breaths per minute
Correct Answer: A,B,E
Rationale: Heat stroke presents with hyperthermia (>104°F, A), tachycardia and hypotension (B, E) due to dehydration and vasodilation. Bradycardia (C) and low respiratory rate (D) are not typical.
The nurse is assisting the health care provider to perform a renal biopsy. Which position should the nurse place the client in?
- A. in the semi-Fowler's position
- B. on the same side of the kidney to be biopsied
- C. on the side opposite of the kidney to be biopsied
- D. prone with a pillow under the shoulders and abdomen
Correct Answer: D
Rationale: The prone position with a pillow under the abdomen (D) provides optimal access to the kidney and stabilizes the client during a renal biopsy.
A nurse is preparing discharge instructions for a client with a below-the-knee amputation. Which instruction would be a priority?
- A. sterile wound management
- B. elevation of residual limb
- C. performing prescribed exercises
- D. reporting occurrence of phantom limb pain immediately
Correct Answer: B
Rationale: Elevating the residual limb (B) is the priority to reduce edema and promote healing post-amputation. Wound care (A), exercises (C), and phantom pain (D) are important but secondary.
A 10-year-old is sent home from school with a report of having lice. The nurse should instruct the parent on which intervention?
- A. wash the hair for three continuous days with dandruff shampoo
- B. isolate all clothing of the child for one week
- C. treat with an approved pediculicide agent according to directions
- D. shave the child's head, then cleanse with herbal shampoo
Correct Answer: C
Rationale: An approved pediculicide (C) is the standard treatment for head lice, following package directions. Dandruff shampoo (A) is ineffective, isolation alone (B) is insufficient, and shaving (D) is unnecessary.