Nokea
After a client diagnosed with pleural effusion had a thoracentesis, a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. Based on this test result, what was the cause of this client's pleural effusion?
- A. Trauma
- B. Infection
- C. Liver failure
- D. Heart failure
Correct Answer: A
Rationale: Pleural fluid from an effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, heart failure, liver or renal failure, malignancy, or inflammatory processes. Infection would be accompanied by white blood cells. The fluid portion of the serum would accumulate with liver failure and heart failure.
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The nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse should instruct mothers to take which action?
- A. If antibiotic ointment has been applied to the cord, it is not necessary to do anything else to it.
- B. All that is necessary is to wash the cord with antibacterial soap and allow it to air-dry once a day.
- C. Apply alcohol thoroughly to the cord, being careful not to move the cord because it will cause pain to the newborn infant.
- D. Apply the prescribed cleansing agent to the cord, ensuring that all areas around the cord are cleaned two to three times a day.
Correct Answer: D
Rationale: The cord and base should be cleansed with alcohol (or another substance as prescribed) thoroughly, two to three times per day. The steps are (1) lift the cord; (2) wipe around the cord, starting at the top; (3) clean the base of the cord; and (4) fold the diaper below the umbilical cord to allow the cord to air-dry and prevent contamination from urine. Antibiotic ointment is not normally prescribed. Continuation of cord care is necessary until the cord falls off within 7 to 14 days. Water and soap are not necessary; in fact, the cord should be kept from getting wet. The infant does not feel pain in this area.
A client experiencing empyema is to have a bedside thoracentesis performed. The nurse plans to have which equipment available in the event that the procedure is not effective?
- A. Code cart
- B. A small-bore needle
- C. Extra-large drainage bottle
- D. Chest tube and drainage system
Correct Answer: D
Rationale: Empyema is the collection of pus within the pleural cavity. If the exudate is too thick for drainage via thoracentesis, the client may require placement of a chest tube to adequately drain the purulent effusion. A small-bore needle would not effectively allow exudate to drain. Options 1 and 3 are also unnecessary.
The nurse should place a client who sustained a head injury in which position to prevent increased intracranial pressure (ICP)?
- A. In left Sims' position
- B. In reverse Trendelenburg
- C. With the head elevated on a small, flat pillow
- D. With the head of the bed elevated at least 30 degrees
Correct Answer: D
Rationale: The client with a head injury is positioned to avoid extreme flexion or extension of the neck and to maintain the head in the midline, neutral position. The head of the bed is elevated to at least 30 degrees or as recommended by the primary health care provider. The client is log rolled when turned to avoid extreme hip flexion.
An assessment of a client's vocal cords requires indirect visualization of the larynx. Which instruction should the nurse give the client to facilitate this procedure?
- A. Try to swallow.
- B. Hold your breath.
- C. Breathe normally.
- D. Roll the tongue to the back of the mouth.
Correct Answer: C
Rationale: Indirect laryngoscopy is done to assess the function of the vocal cords or obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror, head mirror, and light source. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. Swallowing cannot be done with the mirror in place. The procedure takes longer than the time the client would be able to hold the breath, and this action is ineffective anyway. The tongue cannot be moved back because it would occlude the airway.
The nurse in the prenatal clinic is monitoring a client who is pregnant with twins. The nurse monitors the client closely for which priority complication that is associated with a twin pregnancy?
- A. Hemorrhoids
- B. Postterm labor
- C. Maternal anemia
- D. Costovertebral angle tenderness
Correct Answer: C
Rationale: Maternal anemia often occurs in twin pregnancies because of a greater demand for iron by the fetuses. Options 1 and 4 occur in a twin pregnancy but would not be as high a priority as anemia. Option 2 is incorrect because twin pregnancies often end in prematurity.