Nokea
The nurse is caring for a client who is scheduled to have a liver biopsy. Before the procedure, it is important for the nurse to assess which parameter to assure client safety?
- A. Tolerance for pain
- B. Allergy to iodine or shellfish
- C. History of nausea and vomiting
- D. Ability to lie still and hold the breath
Correct Answer: D
Rationale: A liver biopsy is an invasive procedure that involves inserting a needle into the liver to obtain a tissue sample. To ensure client safety, the nurse must assess the client's ability to lie still and hold their breath during the procedure, as movement or breathing can cause complications such as bleeding or injury to surrounding organs. Assessing pain tolerance, allergies to iodine or shellfish, or a history of nausea and vomiting is not directly related to the safety of the liver biopsy procedure.
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The nurse admits a client with a suspected diagnosis of bulimia nervosa. While performing the admission assessment, the nurse expects to elicit which data about the client's beliefs?
- A. Is accepting of body size
- B. Views purging as an accepted behavior
- C. Overeats for the enjoyment of eating food
- D. Overeats in response to losing control of diet
Correct Answer: B
Rationale: Individuals with bulimia nervosa develop cycles of binge eating, followed by purging. They seldom attempt to diet and have no sense of loss of control. Options 1, 3, and 4 are true of the obese person who may binge eat (not purge).
The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addisonian crisis?
- A. Prednisone orally
- B. Fludrocortisone orally
- C. Spironolactone intramuscularly
- D. Methylprednisolone sodium succinate intravenously
Correct Answer: D
Rationale: A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addisonian crisis) that can occur as a result of the adrenalectomy. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid. Spironolactone is a potassium-sparing diuretic.
In preparation to administer an intermittent tube feeding, the nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Which intervention should the nurse implement as a result of this finding?
- A. Discard the aspirate and record as client output.
- B. Mix with new formula to administer the feeding.
- C. Dilute with water and inject into the nasogastric tube.
- D. Reinstill the aspirate through the nasogastric tube via gravity and syringe.
Correct Answer: D
Rationale: After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) to maintain the client's fluid and electrolyte balance. The nurse avoids mixing gastric aspirate with fresh formula to prevent contamination. Because the gastric aspirate is a small volume, it should be reinstilled; however, mixing the formula with water can also disrupt the client's fluid and electrolyte balance unless the client is dehydrated.
What should the nurse consider when determining whether a client diagnosed with a respiratory disease could tolerate and benefit from active progressive relaxation? Select all that apply.
- A. Social status
- B. Financial status
- C. Functional status
- D. Medical diagnosis
- E. Ability to expend energy
- F. Motivation of the individual
Correct Answer: C,D,E,F
Rationale: Active progressive relaxation training teaches the client how to effectively rest and reduce tension in the body. Some important considerations when choosing the type of relaxation technique are the client's physiological and psychological status. Because active progressive relaxation training requires a moderate expenditure of energy, the nurse needs to consider the client's functional status, medical diagnosis, and ability to expend energy. For example, a client with advanced respiratory disease may not have sufficient energy reserves to participate in active progressive relaxation techniques. The client needs to be motivated to participate in this form of alternative therapy to obtain beneficial results. The client's social or financial status has no relationship with her or his ability to tolerate and benefit from active progressive relaxation.
The nurse prepares the client for the removal of a nasogastric tube. During the tube removal, the nurse instructs the client to take which action?
- A. Inhale deeply.
- B. Exhale slowly.
- C. Hold in a deep breath.
- D. Pause between breaths.
Correct Answer: C
Rationale: Just before removing the tube, the client is asked to take a deep breath and hold it because breath-holding minimizes the risk of aspirating gastric contents spilled from the tube during removal. The maneuver partially occludes the airway during tube removal; afterward, the client exhales as soon as the tube is out and thus avoids drawing the gastric contents into the trachea.