Nokea
The nurse is monitoring clients before and after scheduled procedures. Follow-up would be required if the nurse places a client in which position?
- A. Fowler position after a cardiac catheterization via femoral entry
- B. Right side-lying position after a percutaneous liver biopsy
- C. Sims position before a soapsuds enema
- D. Supine position after a lumbar puncture
Correct Answer: D
Rationale: After a lumbar puncture, clients should remain supine for several hours to prevent cerebrospinal fluid leakage and headaches. The right side-lying position is correct post-liver biopsy to prevent bleeding, and Sims position is appropriate for an enema.
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Which discharge teaching instructions should the nurse reinforce to the parents of a 2-year-old with group A streptococcal pharyngitis? Select all that apply.
- A. Complete all the antibiotics even if your child is feeling better
- B. Cool liquids and soft diet are recommended
- C. Keep your child home from daycare for at least a week
- D. Replace your child’s toothbrush 24 hours after starting antibiotics
- E. Throat lozenges may soothe your child’s sore throat
Correct Answer: A,B,D
Rationale: Completing antibiotics prevents resistance, cool liquids/soft foods ease swallowing, and replacing the toothbrush prevents reinfection. A week-long daycare exclusion is excessive (24-48 hours post-antibiotics is sufficient), and lozenges are unsafe for a 2-year-old due to choking risk.
Which of the following are correct nursing actions related to client positioning? Select all that apply.
- A. Position client in Fowler position after cardiac catheterization via femoral entry
- B. Position client in Trendelenburg position on the left side if air embolism is suspected
- C. Position client on the left side following a liver biopsy
- D. Position client on the side with head, back, and knees flexed during lumbar puncture
- E. Position client with the arm raised above the head for chest tube placement
Correct Answer: B,D,E
Rationale: Trendelenburg on the left traps air in the heart’s apex for air embolism, side-lying with flexion aids lumbar puncture access, and arm elevation facilitates chest tube placement. Fowler post-catheterization risks bleeding, and right side-lying is standard post-liver biopsy.
The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond?
- A. Ask the UAP to go back and ask the client what the current needs are
- B. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room
- C. Tell the UAP to inform the client in the next room that the nurse will be there shortly
- D. Tell the UAP to tell the charge nurse about the needs of the client in the next room
Correct Answer: D
Rationale: During moderate sedation, the nurse must remain with the client to monitor vital signs and response. Directing the UAP to inform the charge nurse ensures the other client's needs are addressed without compromising the sedated client's safety. UAP cannot monitor sedation or take over.
Diuretic therapy for hypertension often necessitates the addition of high-potassium foods in the client's diet. Which of the following diuretics does not require the client to increase his intake of potassium?
- A. Spironolactone (Aldactone)
- B. Furosemide (Lasix)
- C. Hydrochlorothiazide (Hydrodiuril)
- D. Ethacrynic acid (Edecrin)
Correct Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic, so clients do not need to increase potassium intake, unlike loop or thiazide diuretics.
Which isolation procedure will be followed for secretions and blood?
- A. Respiratory
- B. Standard Precautions
- C. Contact Isolation
- D. Droplet
Correct Answer: B
Rationale: Standard Precautions apply to all body fluids except sweat, including blood and secretions, to reduce transmission risk in all client interactions. Safety and Infection Control