Nokea
The nurse is positioning a client following a liver biopsy. Which position is best suited for this client?
- A. On the left side with a pillow under the ribs.
- B. Supine with a pillow under the client's knees.
- C. Face down with a pillow under the hips.
- D. On the right side with a pillow under the biopsy site.
Correct Answer: D
Rationale: The right-side position with a pillow under the biopsy site (D) applies pressure to prevent bleeding post-liver biopsy.
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The nurse is caring for a client receiving total parenteral nutrition (TPN) through a central line. The nurse plans on taking which appropriate action?
- A. Inserting an indwelling urinary catheter.
- B. Weighing the client in the morning before the first void.
- C. Placing a mask on the client before changing the central line dressing.
- D. Establishing continuous cardiac monitoring.
Correct Answer: B
Rationale: Weighing the client daily (B) monitors fluid balance and nutritional status, critical for TPN management. Catheters (A), masks (C), and cardiac monitoring (D) are not routinely required unless indicated.
The nurse is assessing a client who has appendicitis. Which of the following would be an expected finding? Select all that apply.
- A. Leukocytosis
- B. Melena
- C. Fever
- D. Nausea and Vomiting
- E. Anorexia
Correct Answer: A,C,D,E
Rationale: Appendicitis commonly presents with leukocytosis (A) due to infection, fever (C) from inflammation, nausea and vomiting (D), and anorexia (E) due to gastrointestinal irritation. Melena (B) is not typically associated with appendicitis.
The nurse is caring for a client who is having a liver biopsy. Which positioning should the nurse place the client in immediately following the procedure?
- A. Supine
- B. Right lateral
- C. Sitting position with legs dangling off the edge of the bed
- D. Left lateral
Correct Answer: B
Rationale: Right lateral positioning (B) applies pressure to the biopsy site, minimizing bleeding risk post-liver biopsy.
The nurse observes a newly hired nurse care for a client with a colostomy. Which action by the newly hired nurse requires follow-up? Select all that apply.
- A. Empties the pouch when it is one-third to one-half full.
- B. Washes the surrounding skin with moisturizing soap.
- C. Indicates that the reddish appearance of the stoma as normal.
- D. Applies sterile gloves prior to changing the device.
- E. Applies isopropyl alcohol to the surrounding skin to promote adherence with the wafer.
Correct Answer: B,D,E
Rationale: Using moisturizing soap (B) can interfere with appliance adhesion, sterile gloves (D) are unnecessary as clean gloves suffice, and isopropyl alcohol (E) can irritate the skin. Emptying the pouch appropriately (A) and recognizing a normal stoma (C) are correct.
The nurse is preparing a client for a scheduled colonoscopy. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP) while the client is preparing for this procedure?
- A. Docusate
- B. Loperamide
- C. Polyethylene glycol 3350
- D. Famotidine
Correct Answer: C
Rationale: Polyethylene glycol 3350 is a bowel preparation agent used to clear the colon for a colonoscopy. Docusate softens stool but is insufficient for prep, loperamide slows motility, and famotidine reduces acid but is not for bowel prep.