Nokea
The nurse is assisting a client who is to undergo a thoracentesis. Which of the following is the optimal position for the procedure?
- A. Lying prone with arms above head
- B. Side lying on the unaffected side
- C. Side lying on the affected side
- D. Upright position, leaning forward over an over-bed tray table
Correct Answer: D
Rationale: The upright position leaning forward (D) maximizes lung expansion and access to pleural fluid during thoracentesis.
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A client's wife states that her elderly husband has begun to slightly slur his words and drop word endings, he has become increasingly withdrawn socially, and he is irritable, accusing her of talking behind his back and whispering at him. The nurse suspects that the client should be initially evaluated for which of the following?
- A. Depression.
- B. Alzheimer's disease.
- C. Hearing loss.
- D. Stroke.
Correct Answer: C
Rationale: Slurred speech, social withdrawal, and irritability with accusations of whispering suggest hearing loss (C), which can cause communication difficulties and paranoia. Depression (A), Alzheimer's (B), and stroke (D) are less likely to present with this specific combination.
The client presents to the emergency room with a hyphema. Which action by the nurse would be best?
- A. Elevate the head of the bed and apply ice to the eye
- B. Place the client in a supine position and apply heat to the knee
- C. Insert a Foley catheter and measure the intake and output
- D. Perform a vaginal exam and check for a discharge
Correct Answer: A
Rationale: Elevating the head and applying ice reduces intraocular pressure and swelling in hyphema, a bleed in the eye.
A client has had a recent below-knee (BK) amputation of the right leg because of a traumatic injury. After removing the elastic wrap, which the client had applied, the nurse notes an unusual pattern of swelling. Which of the following is the most likely reason for this observation?
- A. Wound infection
- B. Impaired circulation to the stump
- C. Incorrect wrap technique
- D. Bleeding into the tissues
Correct Answer: C
Rationale: An unusual swelling pattern after removing an elastic wrap suggests incorrect wrap technique (C), which can cause uneven pressure. Infection (A), impaired circulation (B), or bleeding (D) would present differently.
A client has been receiving Rheumatrex (methotrexate) for severe rheumatoid arthritis. The nurse should tell the client to avoid taking:
- A. Aspirin
- B. Multivitamins
- C. Omega 3 fish oils
- D. Acetaminophen
Correct Answer: A
Rationale: Aspirin can increase methotrexate toxicity by reducing its renal excretion, leading to potentially severe side effects.
When preparing a client for magnetic resonance imaging, the nurse should implement which of the following?
- A. Obtain informed consent and administer atropine 0.4 mg
- B. Scrub the injection site for 15 minutes
- C. Remove any jewelry and inquire about metal implants
- D. Administer Benadryl 50 mg/mL IV
Correct Answer: C
Rationale: MRI safety requires removing jewelry and screening for metal implants to prevent injury from magnetic fields. The other actions are unnecessary or incorrect.