Nokea
The nurse is assisting a primary health care provider with abdominal paracentesis. What position should the nurse assist the client into for this procedure?
- A. Prone
- B. Supine
- C. Semi-Fowler's on the back
- D. Low Fowler's on the right side
Correct Answer: C
Rationale: For abdominal paracentesis, the nurse should position the client in either a semi-Fowler's position or an upright position on the edge of the bed with the feet resting on a stool and the back well supported. This position allows the intestine to float posteriorly and helps prevent laceration during catheter insertion. None of the remaining options suggest the correct position.
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The nurse is assessing a client with a suspected perforated peptic ulcer. Which of the following findings is most indicative of this condition?
- A. Sudden severe abdominal pain.
- B. Chronic epigastric pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Sudden severe abdominal pain is a hallmark sign of a perforated peptic ulcer due to peritoneal irritation.
The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes?
- A. Coordinate documentation of the incident.
- B. Resolve negative feelings and attitudes.
- C. Improve the use of restraint procedures.
- D. Calm down before returning to the other clients.
Correct Answer: C
Rationale: Evaluating restraint incidents aims to improve procedures, ensuring safer and more effective use in the future. Documentation and calming down are secondary, and resolving feelings is not the primary goal.
A client with a history of cirrhosis is admitted with ascites. The nurse should include which of the following in the plan of care?
- A. Administer spironolactone as prescribed.
- B. Restrict sodium intake.
- C. Encourage a high-carbohydrate diet.
- D. Limit fluid intake.
Correct Answer: A, B
Rationale: Spironolactone and sodium restriction reduce fluid retention in ascites.
A client has a prescription to begin short-term therapy with enoxaparin. The nurse explains to the client that this medication is being prescribed for which action?
- A. Dissolve urinary calculi
- B. Relieve migraine headaches
- C. Stop progression of multiple sclerosis
- D. Reduce the risk of deep vein thrombosis
Correct Answer: D
Rationale: Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis and thromboembolism in selected clients at risk. It is not used to treat urinary calculi, migraine headaches, or multiple sclerosis.
What is the term that is used to describe a healthcare related incident or accident that may have possibly led to client harm?
- A. An adverse event
- B. A root cause
- C. A healthcare acquired event
- D. A sentinel event
Correct Answer: A
Rationale: An adverse event is a healthcare-related incident that may have led to client harm, such as medication errors or falls.