Nokea
A delivery room nurse is preparing a client for a cesarean delivery. Which position will promote maximum uteroplacental perfusion during this surgery?
- A. Prone position
- B. Semi-Fowler's position
- C. Trendelenburg's position
- D. Supine position with a wedged right hip
Correct Answer: D
Rationale: Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities, thereby decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, so a wedge placed under the right hip provides displacement of the uterus off of the vena cava. A semi-Fowler's or prone position is not practical for this type of abdominal surgery. Trendelenburg positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation.
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A client with a diagnosis of chronic kidney disease has an indwelling peritoneal catheter in the abdomen for peritoneal dialysis. While bathing, the client spills water on the abdominal dressing. Which action should the nurse perform to best assure client safety?
- A. Change the dressing.
- B. Reinforce the dressing.
- C. Flush the peritoneal dialysis catheter.
- D. Scrub the catheter with povidone-iodine.
Correct Answer: A
Rationale: Clients with peritoneal dialysis catheters are at high risk for infection. A dressing that is wet is a conduit for bacteria to reach the catheter insertion site. The nurse ensures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.
The nurse is preparing to ambulate a client with a diagnosis of Parkinson's disease who has recently been prescribed levodopa. Which information is most important for the nurse to assess before ambulating the client?
- A. The client's history of falls
- B. Assistive devices used by the client
- C. The client's postural (orthostatic) vital signs
- D. The degree of intention tremors exhibited by the client
Correct Answer: C
Rationale: Clients diagnosed with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem is exacerbated with the introduction of levodopa, which can also cause postural hypotension. Although knowledge of the client's risk for falls and the client's use of assistive devices are helpful, it is not the most important piece of assessment data, based on the wording of this question. Clients with Parkinson's disease generally have resting, not intention, tremors.
The nurse documents a written entry regarding client care in the client's medical record. When checking the entry, the nurse notices that some of the documented information was incorrect. Which action should the nurse implement at this time?
- A. Obliterate the incorrect information with a black marker.
- B. Use correction fluid to cover up the incorrect information.
- C. Erase the error completely and write in the correct information.
- D. Draw a line through the incorrect information and initial the change.
Correct Answer: D
Rationale: To correct a written error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. The information remains visible and properly labeled as incorrect. Errors are never erased, and correction fluid or black markers are never used on a legal document such as the medical record.
The nurse is caring for an adolescent client with a diagnosis of conjunctivitis. Which instruction is most appropriate for the nurse to relate to the adolescent?
- A. Avoid using all eye makeup to prevent possible reinfection.
- B. Apply hot compresses to decrease pain and lessen irritation.
- C. Obtain a new set of contact lenses for use after the infection clears.
- D. Isolate for 3 days after beginning antibiotic eye drops to avoid the spread of infection.
Correct Answer: C
Rationale: Conjunctivitis is inflammation of the conjunctiva. A new set of contact lenses should be obtained. If the client has conjunctivitis, eye makeup should be replaced but can still be worn. Cool compresses decrease pain and irritation. Isolation for 24 hours after antibiotics are initiated is necessary.
The nurse prepares a client being discharged from the hospital to receive oxygen therapy at home. Which action should the nurse include in client teaching about oxygen safety?
- A. Holding the oxygen tank on your lap when traveling
- B. Checking the oxygen level of the tank on a regular basis
- C. Lighting candles at least a few feet away from the oxygen tank
- D. Reporting low oxygen levels in the tank to the primary health care provider (HCP)
Correct Answer: B
Rationale: The nurse instructs the client and family to check the oxygen level in the tank on a regular basis to prevent the oxygen from running out. When traveling, the oxygen tank should be secured in place to prevent tank damage and a potentially devastating injury from a moving tank. Oxygen is a highly combustible gas, and, although it will not spontaneously burn or cause an explosion, it contributes to a fire if it contacts a spark from a cigarette, burning candle, or electrical equipment. The nurse instructs the client to contact the oxygen supplier about low oxygen levels in the tank; contacting the HCP is likely to delay prompt replacement of the oxygen tank.