Nokea
The nurse is planning to assist the physician with a thoracentesis for a client who has a pleural effusion. Which of the following positions would be appropriate for the client to assume?
- A. Lying supine with the arms extended.
- B. Lying prone with the head supported by the arms.
- C. Sitting upright and leaning on an overbed table.
- D. Side-lying with the knees drawn up to the abdomen.
Correct Answer: C
Rationale: Sitting upright and leaning on an overbed table facilitates access to the pleural space and ensures client comfort during thoracentesis.
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A 4-year-old child is admitted for a cardiac catheterization. Which of the following is most important to include as the nurse teaches this child about the cardiac catheterization?
- A. A plastic model of the heart.
- B. A catheter that will be inserted into the artery.
- C. The parents.
- D. Other children undergoing a catheterization.
Correct Answer: C
Rationale: Including the parents in teaching provides emotional support and reassurance to the child, which is critical for a 4-year-old facing a procedure. While a model or catheter explanation may be useful, parental presence is most important for the child's comfort and understanding.
Which client should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. A client who needs teaching regarding the use of an incentive spirometer
- B. A client who needs to have a urine specimen collected for a clean catch urine
- C. A client who needs reinforcement of a dressing covering an abdominal incision
- D. A client who needs assessment of a newly identified area of pressure over the right hip
Correct Answer: B
Rationale: The UAP can assist with specimen collection such as a clean catch urine because he or she is trained in this skill. Skills requiring nursing intervention such as dressing changes, teaching, and assessment cannot be delegated to unlicensed personnel.
A client with a history of heart failure is prescribed eplerenone (Inspra). The nurse should monitor the client for which of the following side effects?
- A. Hyperkalemia.
- B. Hypoglycemia.
- C. Weight gain.
- D. Hypertension.
Correct Answer: A
Rationale: Eplerenone, a potassium-sparing diuretic, can cause hyperkalemia, requiring monitoring of potassium levels.
A client diagnosed with trigeminal neuralgia asks the nurse what can be done to minimize the episodes of pain. The nurse's response is based on an understanding that what can trigger the pain?
- A. Infection or stress
- B. Hypoglycemia and fatigue
- C. Facial pressure or extreme temperature
- D. Excessive watering of the eyes or nasal stuffiness
Correct Answer: C
Rationale: The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating and drinking, and yawning. Symptoms can also be triggered by thermal stimuli such as a draft of cold air. The items listed in the other options do not trigger the spasm.
Your 87 year old client has a history of heart disease and fibromyalgia. This client has an internal pacemaker and is also a diabetic client. During your annual visit with this client, the client tells you that they would like to begin some alternative and homeopathic health care practices. What should you include in your teaching plan for this client?
- A. Information about the lack of scientific evidence regarding the effectiveness of all herbs.
- B. Data to support the fact that magnets can be effective in terms of fibromyalgia pain, and as such, may be a good choice for this client.
- C. Research that suggests that prayer is an effective alternative method to relieve pain and stress that can be helpful to this client.
- D. Information that contraindicates the use of biofeedback because this alternative, complementary health practice can interfere with the client's pacemaker functioning.
Correct Answer: C
Rationale: Prayer is a safe and evidence-supported complementary practice that can help reduce stress and pain, suitable for this client. There is insufficient evidence for magnets in fibromyalgia treatment, and biofeedback is not contraindicated for pacemakers. Not all herbs lack scientific evidence, so option A is overly broad.