Nokea
An adult is to have a paracentesis performed today. What should the nurse do before the procedure?
- A. Encourage the client to drink large amounts of fluids
- B. Ask the client to empty her bladder just before the test
- C. Keep the client NPO until after the procedure
- D. Premedicate the client as ordered
Correct Answer: B
Rationale: Emptying the bladder before paracentesis prevents accidental puncture of the bladder during needle insertion into the abdominal cavity. Fluid intake, NPO status, or premedication are not immediate pre-procedure priorities.
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A 5-month-old infant is admitted to the ER with a temperature of 103.6° and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical sign in bacterial meningitis.
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-left quadrant. The infant is most likely in which position?
- A. Left mentum anterior
- B. Left occipital anterior
- C. Left sacral anterior
- D. Left occipital transverse
Correct Answer: B
Rationale: Fetal heart tones loudest in the upper-left quadrant suggest a left occipital anterior position, where the fetus's back is aligned with the mother's left side. Other positions` positions are less likely.
A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's wife reports that she noticed that he acted confused and was extremely weak when he woke up in the morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101°F (38.3°C). A diagnosis of acute adrenal insufficiency is made. Which of the following would the nurse expect to administer by I.V. infusion?
- A. Insulin
- B. Hydrocortisone
- C. Potassium
- D. Hypotonic saline
Correct Answer: B
Rationale: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given 100 mg of hydrocortisone in normal saline every 6 hours until his blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal - not hypotonic - saline solution.
The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
- A. Trendelenburg
- B. Prone
- C. Semi-Fowlers
- D. Side-lying with head flat
Correct Answer: C
Rationale: Semi-Fowlers. Maintaining the head of the bed at 15-30 degrees reduces cerebral venous congestion, helping to manage increased intracranial pressure.
The nurse is caring for a client with a history of diverticulitis. Which of the following dietary recommendations should the nurse provide to prevent flare-ups?
- A. Increase intake of nuts and seeds.
- B. Follow a low-fiber diet.
- C. Consume a high-fiber diet.
- D. Avoid all dairy products.
Correct Answer: C
Rationale: A high-fiber diet promotes regular bowel movements and reduces pressure in the colon, preventing diverticulitis flare-ups. Nuts and seeds (A) may irritate diverticula, a low-fiber diet (B) worsens symptoms, and dairy restriction (D) is unnecessary unless lactose intolerant.