Nokea
The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately?
- A. Asymmetrical chest expansion and decreased breath sounds on the left
- B. Blood pressure 100/65 mm Hg (mean arterial pressure 77 mm Hg)
- C. Client complains of 6/10 pain at the needle insertion site
- D. Respiratory rate 24/min, pulse oximetry 94% on oxygen 2 L/min
Correct Answer: A
Rationale: Asymmetrical chest expansion and decreased breath sounds (A) suggest pneumothorax, a serious post-thoracentesis complication. Hypotension (B), pain (C), and mild tachypnea (D) are less urgent or expected.
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The nurse is floated from the obstetrical (OB) floor to the medical/surgical floor. Which client is the best assignment for the OB nurse?
- A. Female client with a fractured pelvis who is 4 months pregnant
- B. Female client with cytomegalovirus pneumonia
- C. Male client with an open bowel resection with a Foley catheter
- D. Male client with history of Billroth II surgery who is septic
Correct Answer: A
Rationale: The OB nurse’s expertise in pregnancy care makes the pregnant client with a fractured pelvis (A) the best assignment, as it aligns with their skills in managing maternal-fetal health. Other clients (B, C, D) require general medical-surgical care unrelated to OB.
A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the 'evil eye.' The nurse should communicate to other personnel that the appropriate approach is to
- A. Touch the baby after looking at him
- B. Talk very slowly while speaking to him
- C. Avoid touching the child
- D. Look only at the parents
Correct Answer: A
Rationale: In many cultures, an 'evil eye' is cast when looking at a person without touching him. Thus, the spell is broken by touching while looking or assessing.
At 26 weeks gestation, a client is admitted to the ER stating that she has been having a painless bloody vaginal discharge since last evening. The nurse should give priority to:
- A. Reporting the findings to the physician
- B. Evaluating the color of the discharge
- C. Evaluating the client's vital signs
- D. Applying an external fetal monitor
Correct Answer: A
Rationale: Painless bleeding at 26 weeks suggests placenta previa or abruption, requiring immediate physician notification . Assessing discharge , vitals , or fetal monitoring follows reporting.
The doctor has ordered two medications to be given intramuscularly. The nurse should:
- A. Ask the doctor to clarify the order.
- B. Give one injection, wait 30 minutes, and give the other.
- C. Determine whether the medications can be combined.
- D. Administer the injections, one in each hip.
Correct Answer: C
Rationale: The nurse must check if the medications are compatible for combination in one syringe to minimize injections. Administering separately without checking or in specific sites is premature.
A nurse prepared the 9:00 A.M. medications for his clients and then was called off the unit briefly before he was able to administer them. Who may administer the medications to the clients now?
- A. Any licensed nurse assigned to the unit and familiar with the clients
- B. A pharmacy technician certified to administer medications
- C. The nurse who prepared them
- D. The nurse manager of the unit
Correct Answer: C
Rationale: The nurse who prepared the medications must administer them to ensure accountability and familiarity with the preparation.