Nokea
After a lumbar puncture, into which position does the nurse assist the client?
- A. Flat
- B. Semi-Fowler
- C. Side-lying with the head of the bed elevated
- D. Sitting up in a recliner with the feet elevated
Correct Answer: A
Rationale: After a lumbar puncture, the client should be positioned flat. This position helps prevent post-procedure spinal headaches and cerebrospinal fluid leakage. Keeping the client flat for up to 12 hours is crucial in minimizing these risks. Choices B, C, and D are incorrect because elevating the head of the bed or sitting up can increase the risk of complications by altering the pressure in the spinal canal, potentially leading to headaches and fluid leakage.
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A nursing student is suctioning a client through a tracheostomy tube while a nurse observes. Which action by the student would prompt the nurse to intervene and demonstrate the correct procedure? Select all that apply.
- A. Setting the suction pressure to 60 mm Hg
- B. Applying suction throughout the procedure
- C. Assessing breath sounds before suctioning
- D. Placing the client in a supine position before the procedure
Correct Answer: A
Rationale: The correct suction pressure for an adult client with a tracheostomy tube is typically between 80 to 120 mm Hg. Suction should be applied intermittently during catheter withdrawal to avoid damaging the airway. Assessing breath sounds before suctioning is important to ensure the procedure is necessary. Placing the client in a supine position before suctioning can compromise their airway; instead, the head of the bed should be elevated to facilitate proper drainage and reduce the risk of aspiration. Therefore, setting the suction pressure to 60 mm Hg is incorrect and would prompt the nurse to intervene and correct the procedure.
The client with diabetes mellitus is being taught how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.)
- A. I can continue to take an aspirin every 4 to 8 hours for my pain.
- B. My weight should be maintained at a body mass index of 30.
- C. Smoking should be stopped as soon as possible.
- D. A & B
Correct Answer: D
Rationale: The correct answer is D. Both statements A and B indicate a lack of understanding of CKD prevention. Taking aspirin every 4 to 8 hours can lead to kidney damage, and maintaining a body mass index (BMI) of 30 is considered overweight, which can increase the risk of developing CKD. Statement C, on the other hand, correctly addresses smoking cessation, which is crucial in preventing CKD. Therefore, choices A and B are incorrect as they do not align with CKD prevention strategies, making option D the correct choice.
A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client's care?
- A. Edema and pain
- B. Electrolyte and fluid imbalance
- C. Cardiac and respiratory status
- D. Mental health status
Correct Answer: B
Rationale: The major concern for a client admitted with acute kidney injury (AKI) and a high urine output of 2000 mL/day is electrolyte and fluid imbalance. In AKI, there may be an inflammatory cause leading to proteins entering the glomerulus, resulting in fluid being held in the filtrate and causing polyuria. Electrolyte loss and fluid balance are critical to monitor and manage in AKI cases. Edema and pain are not typically associated with fluid loss. While changes in cardiac, respiratory, and mental health status can occur if electrolyte imbalance is not addressed, the primary focus should be on managing electrolyte and fluid balance to prevent further complications.
A client with a chest tube attached to a closed drainage system has undergone a chest x-ray, which revealed that the affected lung is fully reexpanded. The nurse anticipates that the next assessment of the chest tube system will reveal:
- A. No fluctuation in the water seal chamber
- B. Continuous bubbling in the water seal chamber
- C. Increased drainage in the collection chamber
- D. Continuous gentle suction in the suction control chamber
Correct Answer: A
Rationale: When the client's lung is fully reexpanded, the chest tube drainage system will no longer be actively draining, and there will be no fluctuation in the water seal chamber. Option B, continuous bubbling in the water seal chamber, indicates an air leak in the system, which is not expected when the lung is fully expanded. Option C, increased drainage in the collection chamber, would not be expected when the lung is reexpanded as there should be minimal to no drainage. Option D, continuous gentle suction in the suction control chamber, would not be appropriate when the lung is fully reexpanded and the chest tube is typically on a water seal system at this point to promote reexpansion and prevent air from entering the pleural space.
A female patient who is allergic to penicillin will begin taking an antibiotic to treat a lower respiratory tract infection. The patient tells the nurse that she almost always develops a vaginal yeast infection when she takes antibiotics and that she will take fluconazole (Diflucan) with the antibiotic being prescribed. Which macrolide should the nurse question for this patient?
- A. Azithromycin (Zithromax)
- B. Clarithromycin (Biaxin)
- C. Erythromycin (E-Mycin)
- D. Fidaxomicin (Dificid)
Correct Answer: C
Rationale: The nurse should question the prescription of erythromycin for this patient. When erythromycin is given concurrently with fluconazole, erythromycin blood concentration and the risk of sudden cardiac death increase. Therefore, it is not recommended to use erythromycin in combination with fluconazole for this patient. Azithromycin, clarithromycin, and fidaxomicin are alternative macrolide antibiotics that can be considered for this patient without the same risk of interactions when used with fluconazole.