Nokea
The nurse is assessing a client with a suspected appendicitis. Which of the following findings is most indicative of this condition?
- A. Right lower quadrant pain.
- B. Left upper quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Right lower quadrant pain is a hallmark sign of appendicitis due to localized peritoneal irritation.
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The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments?
- A. Interstitial compartment.
- B. Intravascular compartment.
- C. Extracellular compartment.
- D. Intracellular compartment.
Correct Answer: C
Rationale: These symptoms indicate fluid excess in the extracellular compartment, which includes interstitial spaces (edema) and intravascular spaces (contributing to lung crackles).
The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. Which assessment data should the nurse identify as an indicator that the client's lung has completely expanded?
- A. Pleuritic chest pain has resolved.
- B. The oxygen saturation is greater than 92%.
- C. Fluctuations in the water-seal chamber ceased.
- D. Suction in the chest drainage system is no longer needed.
Correct Answer: C
Rationale: When the lung has completely expanded, there is no longer air in the pleural space causing fluctuations in the water-seal chamber. Thus, an indication that a chest tube is ready for removal is when fluctuations in the water-seal chamber cease. Although air is known to be an irritant to pleural tissue, cessation of pleuritic pain does not indicate that the lung is expanded. The chest tube acts as an irritant and therefore contributes to pain. Adequate oxygen saturation does not imply that the lung has fully reexpanded. Use or nonuse of suction in the chest drainage system is not necessarily governed by the degree of lung expansion. Suction is indicated when gravity is not sufficient to drain air and pleural fluid or if the client has a poor respiratory effort and cough.
The nurse is caring for a client who has just undergone a liver biopsy. Which of the following interventions is most important in the immediate post-procedure period?
- A. Keep the client on the right side for 2 hours.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Apply heat to the biopsy site.
Correct Answer: A
Rationale: Keeping the client on the right side for 2 hours post-liver biopsy applies pressure to the site, reducing the risk of bleeding.
Your client has a doctor's order for the antihistamine medication diphenhydramine for sleep. What should you do?
- A. Question the order because Benadryl is an antihistamine and not a sleeping medication.
- B. Refuse to give the Benadryl because this medication is a stimulant.
- C. Question the order because Benadryl is contraindicated when the client has a sleep inducement disorder.
- D. Give the Benadryl because sleep inducement is an accepted off label use of this medication.
Correct Answer: D
Rationale: Diphenhydramine (Benadryl) is commonly used off-label for sleep due to its sedative effects, making it an appropriate choice if ordered for this purpose.
An adult client has bacterial conjunctivitis. What should the nurse teach him to do? Select all that apply.
- A. Use warm saline soaks four times per day to remove crusting.
- B. Apply topical antibiotic without touching the tip of the tube to his eye.
- C. Wash his hands after touching his eyes.
- D. Avoid touching his eyes.
- E. Observe isolation procedures and confine himself to his bedroom until the redness in the eye disappears.
Correct Answer: A,B,C,D
Rationale: Warm saline soaks, careful antibiotic application, hand washing, and avoiding eye contact prevent spread and promote healing. Isolation is unnecessary unless specified.