Nokea
A 32-year-old male client has just undergone a liver biopsy and is released to the post-op floor for observation. The nurse should have the client lie in what position?
- A. semi-Fowler's
- B. on his right side
- C. supine
- D. on his left side
Correct Answer: B
Rationale: Lying on the right side applies pressure to the liver biopsy site, reducing bleeding risk.
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The nurse is caring for a client after an open reduction to the left ulna. The client's left arm is in a plaster cast with an Ace wrap for reinforcement. Which intervention by the nurse can offer nonpharmacological comfort to this client?
- A. elevate the left arm on a pillow and apply an ice pack over the approximate location of the surgical incision
- B. call the physician and obtain an order for acetaminophen (Tylenol) 650 mg PO PRN q6 hours as needed for pain
- C. advise the client that if he starts to itch under the cast, he can use a wire coat hanger or an ink pen to gently scratch up under the cast
- D. perform range-of-motion exercises twice a shift, including bending the fingers, opening and closing the hand, and lifting the arm up to shoulder level
Correct Answer: A
Rationale: Elevation and ice reduce swelling and pain nonpharmacologically. Scratching under the cast risks skin damage, and excessive movement may disrupt healing.
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the physician
- B. Record the reading as the only action
- C. Turn the client and recheck the reading
- D. Place the client supine
Correct Answer: A
Rationale: An ICP of 66 mmHg is critically high (normal <20 mmHg), indicating severe brain swelling. Notifying the physician is urgent for immediate intervention.
Which of the following examples represents parallel play?
- A. Jenny and Tommy share their toys.
- B. Jimmy plays with his car beside Mary, who is playing with her doll.
- C. Kevin plays a game of Scrabble with Kathy and Sue.
- D. Mary plays with a handheld game while sitting in her mother's lap.
Correct Answer: B
Rationale: Parallel play involves children playing side by side with similar toys but without direct interaction, as described in the scenario with Jimmy and Mary.
The nurse is obtaining a history on an 80-year-old client. Which statement made by the client might indicate a potential for fluid and electrolyte imbalance?
- A. My skin is always so dry.
- B. I often use laxatives.
- C. I have always liked to drink a lot of ice tea.
- D. I sometimes have a problem with dribbling urine.
Correct Answer: B
Rationale: Frequent laxative use can lead to dehydration and electrolyte imbalances due to excessive fluid and electrolyte loss through diarrhea.
The nurse in the emergency department is responsible for the triage of four recently admitted clients. Which client should the nurse send directly to the treatment room?
- A. A 23-year-old female complaining of headache and nausea
- B. A 76-year-old male complaining of dysuria
- C. A 56-year-old male complaining of exertional shortness of breath
- D. A 42-year-old female complaining of recent sexual assault
Correct Answer: C
Rationale: Exertional shortness of breath may indicate a cardiac or respiratory emergency, requiring immediate attention.