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A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress. Which of the following actions should the nurse take?
- A. Insert an indwelling urinary catheter and record the client's output.
- B. Set up the equipment using clean technique.
- C. Prepare the client for a chest x-ray following the procedure.
- D. Instruct the client to remain flat in bed for 4 to 6 hr after the procedure.
Correct Answer: C
Rationale: A chest x-ray post-thoracentesis confirms lung re-expansion and checks for complications like pneumothorax.
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A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client had a hemorrhoidectomy 1 year ago.
- B. The client takes ibuprofen for headaches.
- C. The client consumed citrus juice 3 days before the test.
- D. The client has a history of breast cancer.
Correct Answer: B
Rationale: Ibuprofen, an NSAID, can irritate the gastrointestinal tract and cause minor bleeding, potentially leading to a false-positive fecal occult blood test result.
A nurse at an urgent care clinic is contributing to the plan of care for a client following a near drowning while attempting to walk across a frozen pond. Which of the following interventions should the nurse recommend?
- A. Replace wet clothing with warmed blankets.
- B. Use an axillary thermometer to monitor the client's temperature.
- C. Assist the client to perform range-of-motion exercises.
- D. Administer an antihypertensive medication.
Correct Answer: A
Rationale: Replacing wet clothing with warmed blankets prevents hypothermia, a critical risk after a near-drowning incident.
A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?
- A. Unable to repeat the names of three common objects the nurse names.
- B. Unable to answer a judgment question correctly.
- C. Unable to remember their adult children's names.
- D. Unable to remain fully awake while answering questions.
Correct Answer: D
Rationale: Inability to stay awake suggests a serious head injury (e.g., concussion or hemorrhage), making it the priority finding.
A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
The nurse is collecting data on the client. Which of the following findings require follow up?
- A. Findings of right lower extremity assessment
- B. Pain level
- C. Level of consciousness
- D. Oxygen saturation
- E. Right pedal pulses
- F. Temperature
- G. X-ray results
Correct Answer: A,B,E
Rationale: Right lower extremity findings (swelling, open wound), severe pain, and weak right pedal pulses indicate potential fracture or vascular compromise needing follow-up.
A nurse is reinforcing teaching about saturated fats with a client who is at risk for cardiovascular disease. Which of the following cooking fats should the nurse recommend the client use?
- A. Canola oil
- B. Butter
- C. Vegetable shortening
- D. Lard
Correct Answer: A
Rationale: Canola oil is low in saturated fat and heart-healthy, unlike butter, shortening, or lard, reducing cardiovascular risk.