Nokea
A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?
- A. Dorsal recumbent
- B. Supine
- C. High Fowler's
- D. Lithotomy
Correct Answer: B
Rationale: Supine position provides access to the sternum for bone marrow aspiration. Dorsal recumbent (A) is for abdominal exams, High Fowler’s (C) is for breathing, and lithotomy (D) is for pelvic procedures.
You may also like to solve these questions
Upon arrival to the nursery, Ilotycin (erythromycin) eyedrops are instilled in the newborn's eyes. The nurse understands that the medication will:
- A. Make the eyes less sensitive to light
- B. Help prevent neonatal blindness
- C. Strengthen the muscles of the eyes
- D. Improve accommodation to near objects
Correct Answer: B
Rationale: Erythromycin eyedrops are used prophylactically in newborns to prevent ophthalmia neonatorum, which can cause blindness.
The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
- A. Maintaining an adequate level of hydration
- B. Providing pain relief
- C. Preventing infection
- D. O2 therapy
Correct Answer: A
Rationale: Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process.
A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should:
- A. Advise the mother not to give her aspirin
- B. Ask if the client is allergic to aspirin before giving further information
- C. Assess the function of the client's cranial nerve VIII
- D. Check the aspirin bottle label to determine milligrams per tablet
Correct Answer: A
Rationale: Aspirin taken during a viral infection has been implicated as a predisposing factor to Reye's syndrome in children and adolescents. Children and adolescents should not be given aspirin. Allergy to aspirin is not related to Reye's syndrome. Tinnitus, caused by damage to the acoustic nerve, occurs with aspirin toxicity, but this is not related to Reye's syndrome. A 6-year-old child should not be given any baby aspirin.
A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:
- A. In the immediate postpartum period
- B. After the first trimester
- C. At 28 weeks' gestation
- D. Within 72 hours postpartum
Correct Answer: A
Rationale: The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. Rubella infection during the second trimester may result in permanent hearing loss for the fetus. RhoGam is the drug generally administered at 28 weeks' gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. RhoGam is the drug administered within 72 hours postpartum to Rh-negative women to prevent the development of antibodies to fetal cells.
During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
- A. Ignore the client's behavior.
- B. Exchange the cards for a checker board.
- C. Send the other clients to their rooms.
- D. Cover the client and walk her to her room.
Correct Answer: D
Rationale: Covering the client and escorting her to a private area maintains dignity and safety, de-escalating the situation caused by manic behavior.