Nokea
A nurse is caring for a client who is postoperative following a liver biopsy. In which of the following positions should the nurse place the client immediately following the procedure?
- A. Prone
- B. Trendelenburg
- C. High-Fowler's
- D. Right lateral
Correct Answer: D
Rationale: The correct answer is D: Right lateral. Placing the client in a right lateral position post-liver biopsy helps prevent bleeding or hemorrhage by exerting pressure on the biopsy site, aiding in hemostasis. This position also reduces the risk of complications such as pneumothorax. Placing the client in a prone position (A) could increase the risk of bleeding. Trendelenburg position (B) may increase intra-abdominal pressure and the risk of bleeding. High-Fowler's position (C) is not ideal for post-liver biopsy care as it does not provide the necessary pressure to the biopsy site.
You may also like to solve these questions
For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A: Psychosis; B, C, D, E: Mania
Rationale: The correct answer is A: Psychosis; B, C, D, E: Mania. Hallucinations are typically associated with psychosis due to perceptual disturbances. Lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all characteristic features of mania, which is a key symptom of Bipolar Disorder. Mania involves elevated mood, increased energy levels, impulsivity, and risky behavior, such as excessive spending. Disorganized thought process and pressured speech are manifestations of the racing thoughts and flight of ideas seen in mania. In summary, while hallucinations are consistent with psychosis, the other findings (lack of sleep, excessive spending habits, disorganized thought process, pressured speech) are more indicative of mania due to the presence of manic symptoms.
A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
- A. Calcium
- B. Folate
- C. Iron
- D. Zinc
Correct Answer: B
Rationale: The correct answer is B: Folate. Folate is essential for preventing neural tube defects in newborns. It helps in the formation of the neural tube during early pregnancy. Calcium (A) is important for bone health but not specifically for preventing neural tube defects. Iron (C) is crucial for preventing anemia but not directly related to neural tube defects. Zinc (D) is important for immune function and wound healing but not specifically for neural tube defects.
A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Replace the carpet with hardwood floors
- B. Encourage physical activity prior to bedtime
- C. Wear clothing with zippers instead of buttons
- D. Place locks at the tops of exterior doors
Correct Answer: D
Rationale: The correct answer is D: Place locks at the tops of exterior doors. This is important because individuals with Alzheimer's disease may wander and become lost. Placing locks at the tops of exterior doors can help prevent the client from leaving the home unsupervised and potentially getting lost or injured.
A: Replacing the carpet with hardwood floors is not directly related to the safety of the client with Alzheimer's disease.
B: Encouraging physical activity prior to bedtime may actually disrupt sleep patterns for individuals with Alzheimer's disease.
C: Wearing clothing with zippers instead of buttons may not significantly impact the client's safety.
Overall, option D is the most appropriate choice to ensure the safety and well-being of the client with Alzheimer's disease.
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A, B, C, F
Rationale: The correct answer includes findings that are indicative of potential prenatal complications.
A: Urine protein can indicate preeclampsia, a serious condition in pregnancy.
B: Fetal activity changes may suggest fetal distress or growth restriction.
C: Blood pressure changes can indicate hypertension or preeclampsia.
F: Headache can be a symptom of preeclampsia or other serious conditions.
Choices D, E, and G are not typically associated with prenatal complications. D: Urine ketones may indicate dehydration but not necessarily a prenatal complication. E: Respiratory rate is not directly related to prenatal complications. G: Gravida/parity information is important for obstetric history but not directly indicative of current prenatal complications.
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
- A. Tachycardia
- B. Dry cough
- C. Dyspnea
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism indicates a potential respiratory complication, which could be life-threatening. The priority is to report this finding to the provider for prompt evaluation and intervention to prevent further complications. Tachycardia (A) and hypotension (D) may also be concerning but dyspnea takes precedence due to its association with pulmonary embolism. A dry cough (B) may be a common postoperative symptom and not necessarily urgent.