Nokea
A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?
- A. Lying in bed on the affected side
- B. Lying in bed on the unaffected side
- C. Sims position with the head of the bed flat
- D. Prone with the head turned to the side and supported by a pillow
Correct Answer: B
Rationale: The client should be assisted to lie in bed on the unaffected side for a thoracentesis procedure. This position allows for better access to the pleural space for the insertion of a needle to aspirate the fluid or air. Gravity helps to separate the fluid or air, making it closer to the chest wall for easier removal. Additionally, this position reduces the risk of injury to the lung or other structures, as the needle is directed away from these vital structures. Lying on the unaffected side also helps in preventing potential complications and ensures the safety and effectiveness of the procedure.
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The applicant was further asked about an incident report. Which of the following is a PRIORITY Case for an incident report be accomplished?
- A. Patient fell from the bed.
- B. Refusal to go to the physical therapy session.
- C. A visitor encourages a patient on bed rest to ambulate.
- D. Nurse left before his duty ends.
Correct Answer: A
Rationale: A patient falling from the bed is a critical incident that must be prioritized for an incident report. Patient falls can lead to injuries, complications, or even serious consequences. Documenting this incident is crucial for analyzing the cause of the fall, implementing prevention measures, and ensuring patient safety. Additionally, reporting patient falls is a standard practice in healthcare settings to maintain transparency and accountability in patient care.
Patient Josephine was referred to the physician, routine blood examinations were taken. After reviewing the serum electrolyte. levels an order of isotonic intravenous (IV) infusion was prescribed. Which IV solution should the nurse prepare?
- A. 5 percent dextrose in water
- B. 0.45 percent sodium chloride solution
- C. 10 percent dextrose in water
- D. 3 percent sodium chloride solution
Correct Answer: B
Rationale: The order for isotonic intravenous (IV) infusion indicates that the IV solution should have an osmolarity similar to that of blood serum, which is approximately 0.9 percent sodium chloride solution (normal saline). In the given choices, the closest option to isotonic solution is the 0.45 percent sodium chloride solution. This solution is hypotonic compared to blood serum, making it a suitable choice for isotonic IV infusion to prevent fluid shifts and maintain electrolyte balance in the patient. The other options, such as 5 percent dextrose in water (hypotonic), 10 percent dextrose in water (hypertonic), and 3 percent sodium chloride solution (hypertonic), do not match the requirement for an isotonic IV solution in this case.
A patient presents with sudden-onset, severe eye pain, headache, nausea, and vomiting. On examination, the affected eye appears red, with a steamy cornea and mid-dilated, non-reactive pupil. Which of the following conditions is most likely responsible for this presentation?
- A. Acute angle-closure glaucoma
- B. Central retinal artery occlusion
- C. Optic neuritis
- D. Corneal ulcer
Correct Answer: A
Rationale: The clinical presentation described is highly suggestive of acute angle-closure glaucoma. This condition typically presents with sudden-onset severe eye pain, headache, nausea, and vomiting. The red eye, steamy cornea (due to corneal edema), and mid-dilated, non-reactive pupil (from the unopposed force of the dilator muscle) are classic findings in acute angle-closure glaucoma. The increase in intraocular pressure compromises blood flow to the eye, leading to symptoms of blurred vision and possible visual loss. Immediate management usually involves lowering intraocular pressure with medications or surgical intervention to prevent vision loss. Central retinal artery occlusion, optic neuritis, and corneal ulcer typically present with different clinical features and are not consistent with the described presentation.
Which of the following nursing measures would the nurse LEAST CONSIDERS to Patient Ellie with oxytocin drip?
- A. Know, how to recognize potential adverse reactions:
- B. Administer oxytocin drug with caution
- C. Monitor patient closely when infusing oxytocin
- D. Inform patient about potential complications.
Correct Answer: D
Rationale: While all of the nursing measures listed are important considerations when managing a patient receiving oxytocin drip, the nurse would least consider informing the patient about potential complications. The reason for this is that it is the responsibility of the healthcare provider (such as the physician or advanced practice nurse) to inform the patient about potential complications of a medication or treatment. Nurses are instrumental in providing education and support to patients, but in the case of informing patients about potential complications, this task typically falls under the purview of the prescribing provider. The primary focus of the nurse in this situation would be to assess, administer, monitor, and educate the patient as appropriate, ensuring safe and effective care delivery.
A patient presents with foul-smelling diarrhea containing cysts upon microscopic examination. Which of the following parasites is most likely responsible for this infection?
- A. Giardia lamblia
- B. Entamoeba histolytica
- C. Cryptosporidium parvum
- D. Cyclospora cayetanensis
Correct Answer: B
Rationale: Entamoeba histolytica is a parasitic protist known to cause amoebiasis, a gastrointestinal infection that can lead to symptoms such as foul-smelling diarrhea containing cysts. Upon microscopic examination of the feces, the presence of Entamoeba histolytica cysts is a key diagnostic feature. This parasite can be transmitted through contaminated food or water, and individuals infected with Entamoeba histolytica may experience abdominal pain, bloody diarrhea, and weight loss. Proper diagnosis and treatment are essential to manage this infection and prevent complications.