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In assisting a physician to perform a thoracentesis to Mr. Sy, how should the nurse postion a patient with pleural effusion of the left lung?
- A. supine with the left arm extended over the head
- B. sitting at the side of the bed with both arms resting on alocked overbed table
- C. high fowler's with both arms resting on pillows
- D. semi-fowlers with both arms resting on pillows
Correct Answer: B
Rationale: In performing a thoracentesis for a patient with pleural effusion of the left lung, the patient should be positioned sitting at the side of the bed with both arms resting on an overbed table. This position allows for better access to the left lung area and helps the patient maintain a comfortable and stable position during the procedure. Sitting position also helps to expand the intercostal spaces, making it easier for the physician to access the pleural fluid. Additionally, having both arms resting on an overbed table helps the patient remain still and reduce the risk of injury during the procedure. Therefore, this position is the most suitable for performing a thoracentesis for a patient with pleural effusion of the left lung.
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The Foley Family is caring for their youngest child, Justin, who is suffering from tetralogy of Fallot. Which of the following are defects associated with this congenital heart condition?
- A. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two noncommunicating circulations
- B. Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy
- C. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus
- D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle
Correct Answer: B
Rationale: Tetralogy of Fallot is a congenital heart condition characterized by four specific defects:
A client who is receiving cyclosporine (Sandimmune) must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia during long-term therapy with certain drugs. Which of the following drug falls into this category?
- A. Procainamide (Pronestyl)
- B. Phenytoin (Dilantin)
- C. Azathioprine (Imuran)
- D. Allopurinol (Zyloprim)
Correct Answer: B
Rationale: Gingival hyperplasia, or overgrowth of gum tissue, is a common side effect associated with certain medications, particularly anti-seizure medications like phenytoin (Dilantin). This side effect can be minimized through good oral hygiene practices, such as regular brushing and flossing of the teeth. The client must pay extra attention to oral care while taking phenytoin in order to prevent or reduce the severity of gingival hyperplasia. It is important for healthcare providers to educate clients on the importance of oral hygiene with medications associated with this side effect.
A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?
- A. Hematocrit 48%
- B. paCO2 38 mm Hg
- C. platelets 18,000
- D. WBC count 8000
Correct Answer: C
Rationale: A platelet count of 18,000 is significantly low, indicating a condition known as thrombocytopenia, which can lead to a risk of bleeding. In a critical care setting like the ICU, low platelet counts need to be addressed urgently to prevent serious complications such as hemorrhage. This result must be reported immediately to the physician so that appropriate interventions, such as transfusion of platelets, can be initiated promptly to manage the patient's condition effectively. Hematocrit, paCO2, and WBC count may also be important parameters to monitor in an ICU patient, but the critically low platelet count poses the most immediate threat to the patient's well-being and requires urgent attention.
Which intervention should the nurse implement to maintain the skin integrity of the preterm newborn?
- A. Cleanse skin with a gentle alkaline-based soap and water.
- B. Cleanse skin with a neutral pH solution only when necessary.
- C. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
- D. Avoid cleaning skin.
Correct Answer: B
Rationale: Preterm newborns have delicate skin that is more susceptible to damage and irritation. Using a neutral pH solution for cleansing helps to maintain the skin's natural acidity and prevent disruption of the skin barrier. It is important to avoid over-bathing or using harsh alkaline-based soaps that can strip the skin of its natural oils and cause dryness or irritation. Cleansing the skin only when necessary helps to protect the fragile skin of preterm newborns and reduce the risk of skin breakdown or injury.
The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: Pernicious anemia is a type of megaloblastic anemia caused by the body's inability to absorb vitamin B12, essential for the production of red blood cells. The characteristic findings associated with pernicious anemia include pallor due to decreased red blood cells, tachycardia as the heart compensates for decreased oxygen-carrying capacity, and a sore tongue (glossitis) due to vitamin B12 deficiency affecting the oral mucosa. Therefore, the nurse should expect to find pallor, tachycardia, and a sore tongue when assessing a client with pernicious anemia.