Nokea
The nurse is preparing to assist with a lumbar puncture for a client with suspected meningitis. Which of the following positions should the nurse place the client in?
- A. Supine with the head elevated.
- B. Prone with the head turned to one side.
- C. Side-lying with knees flexed to the chest.
- D. Sitting with the back arched.
Correct Answer: C
Rationale: side-lying with knees flexed to the chest maximizes spinal flexion, facilitating access to the subarachnoid space
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The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?
- A. a client who is post-op day 2 from a spinal fusion at L34 with a pain level of 4 on a scale of 1-10
- B. a client with a peripheral IV on a 6-hour infusion with 42 cc remaining
- C. a client who is 6 hours post-atrial fibrillation ablation, is agitated, has a HR of 130 with B/P at 90/50, and has a urine output of 30 cc in the last 2 hours
- D. a client with a nasogastric tube in place who is complaining of gastric distress
Correct Answer: C
Rationale: The client post-atrial fibrillation ablation with agitation, tachycardia (HR 130), hypotension (BP 90/50), and low urine output (30 cc in 2 hours) indicates potential instability, requiring immediate assessment. This takes priority over stable post-op pain, an IV with remaining fluid, or gastric distress.
A client hospitalized with renal calculi complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the client's vital signs that include:
- A. Decreased pulse rate
- B. Increased blood pressure
- C. Decreased respiratory rate
- D. Increased temperature
Correct Answer: B
Rationale: Severe pain from renal calculi can cause increased blood pressure due to sympathetic nervous system activation and stress response.
A client is receiving a blood transfusion following surgery. In the event of a transfusion reaction, any unused blood should be:
- A. Sealed and discarded in a red bag
- B. Flushed down the client's commode
- C. Sealed and discarded in the sharp's container
- D. Returned to the blood bank
Correct Answer: D
Rationale: Unused blood must be returned to the blood bank for analysis in case of a transfusion reaction.
The nurse is caring for a first-time mother who is asking how to help her baby sleep through the night as the baby gets older. Which recommendation should the nurse tell the mother?
- A. Rock her to sleep every night until she is in a deep sleep.
- B. Give diphenhydramine 12.5 mg orally to put the baby to sleep.
- C. If she starts waking up a lot in the middle of the night, put her in the bed with you.
- D. Give the last feeding as late as possible, and put her in the bed awake without a bottle.
Correct Answer: D
Rationale: Placing the baby in bed awake after a late feeding promotes self-soothing and healthy sleep habits, unlike the other options, which may create dependencies or safety risks.
The nurse receives an order to administer 1,500 mL D5W IV over 12 hours. The drop factor is 15 drops/1 mL. The IV flow rate should be set at how many drops per minute? Round to the nearest whole number.
Correct Answer: 31
Rationale: Flow rate (drops/min) = (volume × drop factor) ÷ time. Calculation: (1,500 mL × 15 drops/mL) ÷ (12 × 60) = 22,500 ÷ 720 ≈ 31 drops/min.