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The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the procedure?
- A. Sitting with the arms over the head.
- B. Sims' position.
- C. Prone position without a pillow.
- D. Sitting forward with the arms supported on the bedside table.
Correct Answer: D
Rationale: Sitting forward with arms supported allows optimal access to the pleural space and ensures client comfort during thoracentesis.
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The nurse reviews the serum laboratory results for a client prescribed hydrochlorothiazide. Which most frequent side effect of this medication should the nurse specifically monitor for?
- A. Hypokalemia
- B. Hypocalcemia
- C. Hypernatremia
- D. Hyperphosphatemia
Correct Answer: A
Rationale: The client taking a potassium-losing diuretic must be monitored for decreased potassium levels. Other fluid and electrolyte imbalances that occur with the use of this medication include hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia.
The nurse is caring for a client with a chest tube. Which finding indicates a potential complication?
- A. Continuous bubbling in the water seal chamber.
- B. Fluctuation in the water seal with breathing.
- C. Serosanguineous drainage.
- D. Pain at the insertion site.
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate attention.
Select the risk factor that is accurately paired with its disorder.
- A. Hypernatremia: Hepatic failure
- B. Hypocalcemia: Vitamin A deficiency
- C. Hypermagnesemia: Cushing's disease
- D. Hypomagnesemia: Crohn's disease
Correct Answer: D
Rationale: Hypomagnesemia is associated with Crohn's disease due to malabsorption and chronic diarrhea, which lead to magnesium loss.
Sucking provides the infant with a sense of security and comfort. It also is an outlet for releasing tension. The infant should not be discouraged from sucking on the pacifier. Fussiness after feeding may indicate that the infant's appetite is not satisfied. Sucking is not manipulative in the sense of seeking parental attention.
- A. Encourage the infant to suck on a pacifier.
- B. Discourage pacifier use.
- C. Feed the infant more frequently.
- D. Ignore the infant's fussiness.
Correct Answer: A
Rationale: Sucking on a pacifier is a normal, comforting behavior for infants, supporting emotional regulation.
The nurse is evaluating the laboratory results of a client who was recently admitted to the hospital. Which one of the following results indicates the presence of inflammation?
- A. Decreased sedimentation rate
- B. Thrombocytopenia
- C. Leukocytosis
- D. Erythrocytosis
Correct Answer: C
Rationale: Leukocytosis, an elevated white blood cell count, indicates inflammation or infection. Decreased sedimentation rate, thrombocytopenia, and erythrocytosis are not specific to inflammation.