Nokea
The nurse is caring for a client diagnosed with a herniated lumbar intervertebral disk who is experiencing low back pain. Which position should the nurse place the client in to minimize the pain?
- A. Supine with the knees slightly raised
- B. High Fowler's position with the foot of the bed flat
- C. Semi-Fowler's position with the foot of the bed flat
- D. Semi-Fowler's position with the knees slightly raised
Correct Answer: D
Rationale: Clients with low back pain are often more comfortable in the semi-Fowler's position with the knees raised sufficiently to flex the knees (William's position). This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the bed flat or lying in a supine position with the knees raised would excessively stretch the lower back. Keeping the foot of the bed flat will enhance extension of the spine.
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A client receiving total parenteral nutrition (TPN) through a subclavian catheter suddenly develops dyspnea, tachycardia, cyanosis, and decreased level of consciousness. Based on these findings, which is the best intervention for the nurse to implement for the client?
- A. Obtain a stat oxygen saturation level.
- B. Examine the insertion site for redness.
- C. Perform a stat finger-stick glucose level.
- D. Turn the client to the left side in Trendelenburg's position.
Correct Answer: D
Rationale: Clinical indicators of air embolism include chest pain, tachycardia, dyspnea, anxiety, feelings of impending doom, cyanosis, and hypotension. Positioning the client in Trendelenburg's and on the left side helps isolate the air embolism in the right atrium and prevents a thromboembolic event in a vital organ.
A client who has sustained a neck injury is unresponsive and pulseless. What should the emergency department nurse do to open the client's airway?
- A. Insert oropharyngeal airway.
- B. Tilt the head and lift the chin.
- C. Place in the recovery position.
- D. Stabilize the skull and push up the jaw.
Correct Answer: D
Rationale: The health care team uses the jaw-thrust maneuver to open the airway until a radiograph confirms that the client's cervical spine is stable to avoid potential aggravation of a cervical spine injury. Options 1 and 2 require manipulation of the spine to open the airway, and option 3 can be ineffective for opening the airway.
The nurse performs the Glasgow Coma Scale while assessing a client with a brainstem injury. Which additional interventions should the nurse be prepared to implement? Select all that apply.
- A. Assisting with arterial blood gases
- B. Assisting with a lumbar puncture
- C. Assessing cranial nerve functioning
- D. Assessing respiratory rate and rhythm
- E. Assessing pulmonary wedge pressure
- F. Assessing cognitive abilities, including memory
Correct Answer: C,D
Rationale: Assessment should be specific to the area of the brain involved. Assessing the respiratory status and cranial nerve function is a critical component of the assessment process in a client with a brainstem injury because the respiratory center is located in the brainstem. Options 1, 2, 5, and 6 are not necessary based on the data in the question.
A client's telemetry monitor displays ventricular tachycardia. Upon reaching the client's bedside, which action should the nurse take first?
- A. Call a code.
- B. Prepare for cardioversion.
- C. Prepare to defibrillate the client.
- D. Check the client's level of consciousness.
Correct Answer: D
Rationale: Determining unresponsiveness is the first assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, assessing for unresponsiveness helps determine whether the client is affected by the decreased cardiac output. If the client is unconscious, then cardiopulmonary resuscitation is initiated.
Which important parameter should the nurse assess on a daily basis for a client diagnosed with nephrotic syndrome?
- A. Weight
- B. Albumin levels
- C. Activity tolerance
- D. Blood urea nitrogen (BUN) level
Correct Answer: A
Rationale: The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake and output, edema, and girth measurements. Albumin levels are monitored as they are prescribed, as are the BUN and creatinine levels. The client's activity level is adjusted according to the amount of edema and water retention.