Nokea
The nurse assists a health care provider in performing a liver biopsy. After the biopsy, the nurse should place the client in which position?
- A. Prone
- B. Supine
- C. A left side-lying position with a small pillow or folded towel under the puncture site
- D. A right side-lying position with a small pillow or folded towel under the puncture site
Correct Answer: C
Rationale: Placing the client in a left side-lying position after a liver biopsy helps to promote pressure on the puncture site, which can reduce the risk of bleeding. Placing a small pillow or folded towel under the puncture site provides additional support and helps to maintain pressure on the area. This position also helps prevent the client from putting pressure on the abdomen, which could potentially affect the biopsy site and increase the risk of bleeding or complications. Overall, positioning the client on the left side with support under the puncture site is the most appropriate and safest option after a liver biopsy.
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You are a Drug Abuse Treatment and Rehabilitation Center Nurse. During the assessment of a newly admitted Person Who Uses Drugs (PWUDs) named Korino, which of the following is the MOST APPROPRIATE question to ask?
- A. Ask Korino how long he thought that he could take drugs without someone finding it.
- B. Ask Korino why he started taking illegal drugs.
- C. Not ask any questions for fear Korino will deny and may become assaultive.
- D. Ask Korino about the amount of drug used and its effect and how long he had been using.
Correct Answer: D
Rationale: The most appropriate question to ask during the assessment of a newly admitted Person Who Uses Drugs (PWUDs) like Korino is to ask about the amount of drug used, its effects, and how long he has been using. This question provides valuable information for treatment planning and understanding the extent of Korino's drug use. By asking about the specific details of his drug use, the nurse can assess the severity of the addiction, potential health risks, and the duration of substance abuse. This information is crucial for developing an individualized treatment plan and providing appropriate care for Korino's needs. Asking open-ended questions about drug use also helps build rapport and trust between the nurse and the patient, which is essential for effective treatment.
Which nursing intervention constitutes false imprisonment?
- A. A client is hospitalized as an involuntary admission and attempts to leave the unit. The nurse calls the security team per hospital protocol. They prevent the client from leaving.
- B. A psychotic client is admitted as an involuntary client and runs out of the psychiatric unit. The nurse runs after the client and succeeds in talking the client into returning to the unit.
- C. The client has been "pesky," seeking the attention of nurses in the nurses' station much of the day.
- D. The client is confused, combative, and insists that no one can stop him from leaving. The nurse restrains the client without a physician's order, then seeks the order.
Correct Answer: D
Rationale: False imprisonment occurs when a client is physically restrained or confined without legal justification. In this scenario, the nurse restraining the confused and combative client without a physician's order constitutes false imprisonment. Restraints should only be used when necessary to ensure the safety of the client or others, and a physician's order is required to authorize their use. In this case, the nurse acted without proper authorization, making it a violation of the client's rights and false imprisonment. It is essential to follow proper protocols and obtain necessary orders before restraining a client.
A patient with a history of heart failure is prescribed digoxin. Which assessment finding indicates a potential adverse effect of digoxin therapy?
- A. Bradycardia
- B. Hypotension
- C. Hyperkalemia
- D. Confusion
Correct Answer: D
Rationale: Confusion is a potential adverse effect of digoxin therapy. Digoxin toxicity can manifest as various central nervous system symptoms, including confusion, delirium, and disorientation. It is important to monitor for signs of digoxin toxicity in patients taking this medication, especially those with a history of heart failure or renal impairment. Other common signs of digoxin toxicity may include visual disturbances (like halos around lights), gastrointestinal symptoms (like nausea and vomiting), and cardiac arrhythmias. Monitoring serum digoxin levels can help guide therapy and identify toxicity early.
Which of the following laboratory findings is most consistent with acute respiratory distress syndrome (ARDS)?
- A. Elevated serum bicarbonate (HCO3-) level
- B. Decreased serum albumin level
- C. Elevated white blood cell count (WBC)
- D. Increased lactate dehydrogenase (LDH) level
Correct Answer: D
Rationale: Acute respiratory distress syndrome (ARDS) is a severe condition characterized by widespread inflammation in the lungs leading to increased pulmonary vascular permeability, non-cardiogenic pulmonary edema, and respiratory failure. In ARDS, the alveolar-capillary barrier is disrupted, resulting in fluid accumulation in the alveoli and impaired gas exchange.
A patient presents with sudden-onset severe lower abdominal pain, nausea, vomiting, and inability to pass urine. On physical examination, there is suprapubic tenderness and a palpable bladder. What is the most likely diagnosis?
- A. Acute pyelonephritis
- B. Acute urinary retention
- C. Renal colic
- D. Bladder cancer
Correct Answer: B
Rationale: The patient's presentation with sudden-onset severe lower abdominal pain, nausea, vomiting, inability to pass urine, suprapubic tenderness, and a palpable bladder is classic for acute urinary retention. Acute urinary retention is a urological emergency characterized by the sudden inability to pass urine due to the inability to empty the bladder completely. The palpable bladder on physical examination indicates significant bladder distension. This condition can be caused by multiple factors such as bladder outlet obstruction, neurogenic causes, or medications affecting bladder function. Prompt intervention is necessary to relieve the bladder distension, alleviate symptoms, and prevent complications like bladder rupture.