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A nurse is planning care for a client who underwent a percutaneous needle biopsy of the kidney. What should the nurse plan to do immediately after the biopsy? Select all that apply.
- A. Assess the biopsy site.
- B. Take vital signs every hour.
- C. Assess urine for hematuria.
- D. Place the client in a prone position.
- E. Assess the client for chest pain.
Correct Answer: A,C,D
Rationale: Assessing the biopsy site, urine for hematuria, and placing the client prone help monitor for bleeding and promote hemostasis post-biopsy.
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Which client position is contraindicated for a client with a spinal cord injury?
- A. Supine with head flat.
- B. Logrolling technique.
- C. Head elevated 30 degrees.
- D. Neutral neck alignment.
Correct Answer: A
Rationale: Supine with head flat is contraindicated as it may increase spinal pressure; other positions support alignment and safety.
A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival?
- A. Reflexes.
- B. Bladder function.
- C. Blood pressure.
- D. Temperature.
- E. Respirations.
Correct Answer: C,E
Rationale: Respirations and blood pressure are the priority assessments for a C7 spinal cord injury, as this level can impair diaphragmatic function and cause neurogenic shock, both life-threatening. Reflexes, bladder function, and temperature are important but secondary to airway and circulation stability.
The nurse is preparing to transfuse fresh frozen plasma (FFP) to a client. Which of the following actions would be appropriate for the nurse to take?
- A. Obtain baseline platelet count
- B. Verify ABO compatibility
- C. Infuse over two to four hours
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: FFP requires ABO compatibility verification to prevent transfusion reactions, as it contains plasma proteins and antibodies. Platelet counts are irrelevant to FFP, infusion time is typically 30–60 minutes, and an ECG is not routinely required.
A client in hospice care is experiencing noisy, gurgling respirations. The nurse should:
- A. Suction the airway.
- B. Administer oxygen at 6 L/min.
- C. Reposition the client to a lateral position.
- D. Increase I.V. fluids.
Correct Answer: C
Rationale: Noisy, gurgling respirations (death rattle) are best managed by repositioning to a lateral position to allow secretions to drain, improving comfort without invasive measures.
The client with tuberculosis is to be discharged home with community health nursing follow-up. Of the following nursing interventions, which should have the highest priority?
- A. Offering the client emotional support.
- B. Teaching the client about the disease and its treatment.
- C. Coordinating various agency services.
- D. Assessing the client's environment for sanitation.
Correct Answer: B
Rationale: Teaching about the disease and treatment is the priority to ensure adherence to the lengthy regimen, preventing relapse or resistance. Emotional support, agency coordination, and sanitation are important but secondary.