Nokea
During thoracentesis, which of the following nursing intervention will be most crucial?
- A. Place patient in a quiet and cool room
- B. Maintain strict aseptic technique
- C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
- D. Apply pressure over the puncture site as soon as the needle is withdrawn
Correct Answer: B
Rationale: Maintaining strict aseptic technique during thoracentesis is the most crucial nursing intervention. Thoracentesis is a procedure where a needle is inserted into the pleural space to obtain a sample of fluid for diagnostic purposes or to drain excess fluid for therapeutic relief. It is essential to prevent the introduction of pathogens or contaminants into the pleural space, as this can lead to serious complications such as infection. By following strict aseptic technique, the risk of complications can be minimized, ensuring the safety and well-being of the patient undergoing the procedure.
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A patient teaching plan should include which of the ff. lifestyle modifications to help control hypertension?
- A. Regular aerobic exercise
- B. Three alcoholic beverages per day
- C. Low-tar cigarettes
- D. Daily multivitamin supplements
Correct Answer: A
Rationale: Regular aerobic exercise is an essential lifestyle modification to help control hypertension. Exercise can help lower blood pressure, improve cardiovascular health, and reduce the risk of developing hypertension. Physical activity strengthens the heart, making it more efficient in pumping blood, which can lead to lower blood pressure levels. Additionally, exercise helps in weight management, which is crucial in controlling hypertension as obesity is a significant risk factor for high blood pressure. Overall, incorporating regular aerobic exercise into a patient's routine can significantly contribute to better blood pressure control and overall health.
Morphine is given in acute pulmonary edema to redistribute the pulmonary circulation to the periphery by decreasing:
- A. Periphery resistance
- B. Pulmonary capillary pressure
- C. Transudation of fluid
- D. All of the above CARING FOR CLIENTS WITH HEART FAILURE
Correct Answer: B
Rationale: Morphine is given in acute pulmonary edema to decrease pulmonary capillary pressure. By reducing pulmonary capillary pressure, morphine helps to redistribute the pulmonary circulation to the periphery, leading to improved oxygenation and decreased symptoms of pulmonary edema. Morphine works to vasodilate the blood vessels, which ultimately helps decrease the pressure in the pulmonary capillaries, allowing for improved blood flow to the periphery of the lungs. This redistribution of pulmonary circulation helps to alleviate the congestion and fluid buildup in the lungs that occurs in acute pulmonary edema.
All the following are features of rapid eye movement (REM) EXCEPT
- A. polysomnography
- B. EEG
- C. fibro-optic nasopharngeal examination
- D. CT scan of head and neck
Correct Answer: D
Rationale: CT scan of head and neck is not a feature of REM sleep; it is an imaging study unrelated to the physiological characteristics of REM sleep.
The parent of a 2-week-old infant, exclusively breastfed, asks the nurse if fluoride supplements are needed. What is the nurse's best response?
- A. "She needs to begin taking them now."
- B. "They are not needed if you drink fluoridated water."
- C. "She may need to begin taking them at age 4 months."
- D. "She can have infant cereal mixed with fluoridated water instead of supplements."
Correct Answer: B
Rationale: The nurse's best response to the parent of a 2-week-old infant, exclusively breastfed, regarding the need for fluoride supplements is that they are not needed if the infant is already drinking fluoridated water. Fluoride supplements are typically recommended for infants who are not receiving enough fluoride through their water source. Breast milk itself does not contain a significant amount of fluoride, but if the family's water supply is fluoridated, the infant will likely receive an adequate amount of fluoride without the need for supplements. It is important for the parent to verify the fluoride content of their water supply with their local water utility to ensure the infant is receiving the appropriate amount of fluoride for dental health.
A patient with a history of haemophilia A arrives in the emergency department complaining of a "funny feeling" in his elbow. The patient states that he thinks he is bleeding into the joint. Which response by the nurse is correct?
- A. Palpate the patient's elbow to assess for swelling.
- B. Notify the physician immediately and expect an order for factor VIII.
- C. Prepare the patient for an x-ray examination to determine whether bleeding is occurring.
- D. Apply heat to the patient's elbow and wait for the physician to examine the patient.
Correct Answer: B
Rationale: For a patient with a history of hemophilia A complaining of a "funny feeling" in the elbow, suspecting bleeding into the joint, the correct response by the nurse is to notify the physician immediately and expect an order for factor VIII. Hemophilia A is a genetic disorder characterized by a deficiency in clotting factor VIII, leading to prolonged bleeding. In this case, immediate medical intervention in the form of factor VIII replacement therapy is crucial to control and manage the bleeding episode. Urgent treatment aims to prevent complications such as joint damage and to promote hemostasis in patients with hemophilia. Palpating the elbow, preparing for an x-ray, or applying heat are not the appropriate initial actions when managing a suspected bleeding episode in a patient with hemophilia.