Nokea
The nurse helps the health care provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort?
- A. Fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them
- B. Lying on the affected side with head of the bed elevated to 30-45 degrees
- C. Prone with head turned to the affected side and arms over the head, supported by a pillow
- D. Upright leaning forward over the bedside table, with arms supported on pillows
Correct Answer: D
Rationale: Upright leaning forward (D) facilitates lung expansion and fluid access while ensuring comfort. Other positions (A, B, C) are less effective or uncomfortable.
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A 70 year-old post-operative client has elevated serum BUN, HCT, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:
- A. Impaired gas exchange
- B. Metabolic acidosis
- C. Renal insufficiency
- D. Fluid volume deficit
Correct Answer: D
Rationale: Fluid volume deficit. In fluid volume deficit, serum BUN, Na+, and hematocrit may be elevated secondary to hemoconcentration.
The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply.
- A. Date of birth
- B. First and last name
- C. Health care provider
- D. Medical record number
- E. Room number
Correct Answer: A, B, D
Rationale: Date of birth (A), first and last name (B), and medical record number (D) are reliable identifiers. Health care provider (C) and room number (E) are not specific to the client.
When giving an intramuscular injection to an infant. Which of the following sites is preferred?
- A. Ventrogluteal region
- B. Deltoid
- C. Vastus lateralis
- D. Dorsogluteal region
Correct Answer: C
Rationale: Vastus lateralis is the ideal choice for infants.
The nurse is caring for a client with Guillain-Barré syndrome after a recent gastrointestinal illness. Monitoring for which symptom is a nursing care priority in this client?
- A. Diaphoresis with facial flushing
- B. Hypoactive or absent bowel sounds
- C. Inability to cough or lift the head
- D. Warm, tender, and swollen leg
Correct Answer: C
Rationale: Inability to cough or lift the head (C) indicates respiratory muscle weakness, a life-threatening complication in Guillain-Barré syndrome, making it the priority.
A recovering alcoholic asked the nurse, 'Will it be ok for me to just drink at special family gatherings?' Which initial response by the nurse would be best?
- A. A recovering person has to be very careful not to lose control, therefore, confine your drinking only to family gatherings.
- B. At your next AA meeting discuss the possibility of limited drinking with your sponsor.
- C. A recovering person needs to get in touch with their feelings. Do you want a drink?
- D. A recovering person cannot return to drinking without starting the addiction process over.
Correct Answer: D
Rationale: A recovering person cannot return to drinking without starting the addiction process over. Total abstinence is required to maintain recovery.