Nokea
A client is scheduled to undergo a bone marrow aspiration. Which position would the nurse assist the client into for this procedure?
- A. Dorsal recumbent
- B. Supine
- C. High Fowler's
- D. Lithotomy
Correct Answer: A
Rationale: The dorsal recumbent position is used for bone marrow aspiration, typically performed on the iliac crest, allowing access and patient comfort. Supine, High Fowler's, and lithotomy positions are not suitable, so B, C, and D are incorrect.
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The nurse is caring for an adult who has myasthenia gravis and is prescribed neostigmine. Which drug should the nurse plan to have readily available because the client is taking neostigmine?
- A. Atropine
- B. Vitamin K
- C. Protamine sulfate
- D. Calcium gluconate
Correct Answer: A
Rationale: Neostigmine, a cholinesterase inhibitor, can cause cholinergic crisis; atropine, an anticholinergic, is the antidote to reverse excessive muscarinic effects.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise
The nurse is observing a certified nursing assistant (CNA) caring for a client who has AIDS. Which action, if observed, is not correct?
- A. The CNA wears gloves when cleaning the client after an episode of fecal incontinence.
- B. The CNA uses chlorine bleach to wipe up blood after the client cut himself shaving.
- C. The CNA is observed giving the client a back rub without gloves on.
- D. The CNA wears a mask whenever entering the client's room.
Correct Answer: C
Rationale: Standard precautions require gloves during contact with non-intact skin or bodily fluids, including during a back rub for an AIDS client, to prevent transmission. Gloves for incontinence, bleach for blood, and masks (if indicated) are appropriate.
The nurse is preparing a client with a severe case of inflamed hemorrhoids for a rectal examination by the physician. What is the best position to place her in on the examination table?
- A. Dorsal recumbent
- B. Knee-chest
- C. Sims'
- D. Lithotomy
Correct Answer: B
Rationale: The knee-chest position provides optimal exposure for rectal examination, minimizing discomfort with inflamed hemorrhoids.
A diabetic client asks the nurse why the provider ordered a glycosylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:
- A. Provides a more precise blood glucose value than self-monitoring
- B. Is performed to detect complications of diabetes
- C. Measures circulating levels of insulin
- D. Reflects an average blood sugar for several months
Correct Answer: D
Rationale: Glycosylated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 2-3 months and can be used to monitor client adherence to the therapeutic regimen.