Nokea
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.
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While assisting the physician with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following?
- A. Intrauterine infection.
- B. Fetal meconium staining.
- C. Erythroblastosis fetalis.
- D. Normal amniotic fluid.
Correct Answer: B
Rationale: Cloudy, thick amniotic fluid often indicates meconium staining, suggesting fetal distress, which requires further evaluation.
A client has a history of syphilis infection. The nurse interprets that the client has been re-infected when which characteristic is noted in a penile lesion?
- A. Papular areas and erythema
- B. Cauliflower-like appearance
- C. Induration and absence of pain
- D. Multiple vesicles, with some that have ruptured
Correct Answer: C
Rationale: The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Scabies is characterized by erythematous, papular eruptions. Genital warts are characterized by cauliflower-like growths, or growths that are soft and fleshy. Genital herpes is accompanied by the presence of one or more vesicles that then rupture and heal.
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 discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says:
- A. If I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: D
Rationale: Clients with preterm labor should get out of the car every 1-2 hours to promote circulation and prevent complications, not every 4 hours, indicating a need for further instruction.
A client with a urinary tract infection is prescribed ciprofloxacin. What should the nurse include in the teaching?
- A. Take the medication with dairy products.
- B. Report tendon pain or swelling.
- C. Increase fluid intake to 1 L/day.
- D. Avoid sunlight exposure completely.
Correct Answer: B
Rationale: Ciprofloxacin can cause tendonitis or tendon rupture, so reporting tendon pain or swelling is critical.