Nokea
The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?
- A. In the supine position
- B. Lying on the unaffected side
- C. In the high Fowler's position
- D. Prone with a pillow under the head
Correct Answer: B
Rationale: Following a thoracentesis, the client remains on bed rest and typically lies on the unaffected side for at least 1 hour to promote expansion of the lung on the affected side. Lying flat in a supine position or prone does not promote expansion of the lung.
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The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?
- A. The nursing assistant is assisting the client to a semi-Fowler's position.
- B. The nursing assistant is assisting the client to the side of the bed to use a urinal.
- C. The nursing assistant is pouring a glass of water to wet the client's mouth.
- D. The nursing assistant is asking a question requiring a verbal response.
Correct Answer: C
Rationale: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post-procedure period.
A client presents to the emergency department in respiratory compromise. The client's temperature is 102.4?°F, heart rate 88 beats/minute and regular, and blood pressure 138/76 mm Hg. The client is dyspneic, pale, and expectorating green-tinged sputum. The physician orders medications including antibiotics, antipyretics, nebulizer treatments, and IV fluids. A chest x-ray and sputum culture are to be completed. Which physician order would the nurse complete before beginning antibiotic therapy?
- A. Chest x-ray
- B. Sputum culture
- C. Nebulizer treatments
- D. Initiating IV fluids
Correct Answer: B
Rationale: The nurse would obtain a sputum culture for sensitivity before beginning antibiotic therapy. Obtaining a sputum culture after beginning antibiotics can skew results. Once the sputum culture results are returned, the antibiotic can be closely aligned to kill the organism, if present. The other orders can be prioritized according to client needs.
What happens to the diaphragm during inspiration?
- A. It relaxes and raises.
- B. It contracts and flattens.
- C. It relaxes and flattens.
- D. It contracts and raises.
Correct Answer: B
Rationale: During inspiration, the diaphragm contracts and flattens, which expands the thoracic cage and increases the thoracic cavity.
The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?
- A. Medulla oblongata, cerebellum, and heart rate
- B. Pons, cerebellum, and oxygen receptors
- C. Medulla oblongata, mitral valve, and central receptors
- D. Aortic arch, pons, and CO2 receptor sites
Correct Answer: D
Rationale: Several mechanisms control ventilation. The respiratory center in the medulla oblongata and pons control rate and depth of respirations. The central chemoreceptors in the medulla and peripheral chemoreceptors in the aortic arch also provide a mechanism for detecting abnormalities and signal changes to alter the pH and levels of oxygen in the blood. The other options have an incorrect piece of the triad.
The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?
- A. Bleeding
- B. Iodine allergy
- C. Dysrhythmias
- D. Inflammation
Correct Answer: B
Rationale: During lung scans, a radioactive contrast medium is administered intravenously for the perfusion scan. Before the perfusion scan, nurses must assess the client to check for allergies to iodine. Laryngoscopy determines inflammation. Dysrhythmias and bleeding are possible complications of mediastinoscopy.