Nokea
A client is about to undergo bone marrow aspiration of the sternum. Which of the following statements should the nurse include to provide information to the client about what the client will feel during the procedure?
- A. You may feel a warm solution being wiped over your entire front from your neck down to your navel and out to your shoulders.'
- B. You will not feel the local anesthetic being applied because it will be sprayed on.'
- C. You will feel a pulling type of discomfort for a few seconds.'
- D. After the needle is removed, you will feel a bandage being applied around your chest.'
Correct Answer: C
Rationale: During sternal bone marrow aspiration, the client may feel a brief pulling or pressure sensation as the marrow is aspirated. The antiseptic solution is not applied over such a large area, local anesthetic is injected (not sprayed), and a bandage is applied to the site, not around the chest.
You may also like to solve these questions
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Excessive sweating above the injury level.
- D. Numbness in the lower extremities.
Correct Answer: C
Rationale: Excessive sweating above the injury level is a hallmark symptom of autonomic dysreflexia, a medical emergency.
A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when his vital signs suddenly change. In addition to notifying the physician, what other action should the nurse take immediately?
- A. Administer oxygen.
- B. Elevate the head of the bed 30 degrees.
- C. Administer a bolus of I.V. fluids.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Sudden vital sign changes post-gastrectomy suggest hypoxia or shock. Administering oxygen addresses potential respiratory compromise, a common postoperative issue, while awaiting physician guidance.
A 56-year-old cancer survivor feels guilty at the 'I Can Cope' meetings. The nurse can help him manage his feelings of guilt by pointing out that:
- A. He is really angry at the terminally ill clients in the group.
- B. He is experiencing very volatile emotions.
- C. This is a spiritual response to his illness.
- D. This is a normal reaction when surviving a life-threatening experience.
Correct Answer: D
Rationale: Survivor guilt is a normal reaction for cancer survivors, especially in support groups, and acknowledging this helps the client process their emotions.
Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client?
- A. Assessing the client's skin color.
- B. Abrupting the respiratory rate.
- C. Verifying the amount of cuff inflation.
- D. Auscultating breath sounds bilaterally.
Correct Answer: D
Rationale: Auscultating bilateral breath sounds confirms correct endotracheal tube placement in both lungs. Skin color, respiratory rate, and cuff inflation are less specific.
A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that:
- A. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect.
- B. Nitroglycerin should be avoided if the client is experiencing this serious side effect.
- C. Taking the nitroglycerin with a few glasses of water will reduce the problem.
- D. The client should lie in a supine position to alleviate the headache.
Correct Answer: A
Rationale: Headache is a common side effect of nitroglycerin due to vasodilation. Acetaminophen or ibuprofen can safely relieve it without discontinuing the medication.