Nokea
The nurse is preparing a client for a paracentesis. The nurse should:
- A. Have the client void immediately before the procedure.
- B. Place the client in a side-lying position.
- C. Initiate an I.V. line to administer sedatives.
- D. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.
Correct Answer: A
Rationale: Voiding before paracentesis (A) prevents bladder injury. Side-lying (B) is incorrect; upright is preferred. IV sedatives (C) are not routine, and NPO (D) is unnecessary.
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The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" × 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
- A. Stage I pressure ulcer.
- B. Stage II pressure ulcer.
- C. Stage III pressure ulcer.
- D. Stage IV pressure ulcer.
Correct Answer: B
Rationale: A Stage II pressure ulcer involves partial-thickness skin loss extending to the dermis, matching the description of the sacral breakdown.
The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following:
- A. Turning every 2 hours
- B. Passive and active range-of-motion exercises
- C. Use of thromboembolic disease support (TED) hose
- D. Maintaining the client in the supine position
Correct Answer: D
Rationale: Maintaining the client in the supine position is not recommended, as it promotes stasis and pressure ulcers. Turning every 2 hours, range-of-motion exercises, and TED hose prevent complications like thrombophlebitis and skin breakdown during bed rest.
The nurse asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment. The nurse does this to monitor for signs of which of the following?
- A. External hemorrhage.
- B. Decreasing level of consciousness.
- C. Laryngeal nerve damage.
- D. Upper airway obstruction.
Correct Answer: C
Rationale: Asking the client to speak monitors for laryngeal nerve damage, which can cause vocal cord paralysis and hoarseness, a potential complication of thyroidectomy.
Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia?
- A. Introduce the client to other people who are successfully managing their care.
- B. Include the client's daughter in the teaching so that she can help implement the plan.
- C. Ask the client to identify other situations in which he demonstrated responsibility for himself.
- D. Reassure client that he will be able to implement all aspects of the plan successfully.
Correct Answer: C
Rationale: Encouraging the client to identify past instances of responsibility promotes self-efficacy and motivates self-care behaviors, which is most effective for long-term management.
A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care?
- A. Remove the dressing and leave the incision open to air.
- B. Remove the drain if wound drainage is minimal.
- C. Gently irrigate the drain to remove exudate.
- D. Clean the area around the drain moving away from the drain.
Correct Answer: D
Rationale: When providing wound care, the nurse should clean the area around the drain moving away from the drain to prevent introducing pathogens into the wound. Leaving the incision open, removing the drain, or irrigating are not appropriate without specific orders. CN: Physiological adaptation; CL: Synthesize