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The nurse prepares a client with the diagnosis of right pleural effusion for a thoracentesis; however, the client experiences severe dizziness when sitting upright. Which alternate position should the nurse assist the client into to maintain safety during the procedure?
- A. Right side-lying with the head of the bed flat
- B. Prone with the head turned toward the affected side
- C. Sims' position with the head of the bed elevated 45 degrees
- D. Left side-lying with the head of the bed elevated 45 degrees
Correct Answer: D
Rationale: A thoracentesis is a procedure in which fluid or air is removed from the pleural space via a transthoracic aspiration. Positioning can help isolate the fluid in a pleural effusion; generally, the client sits at the edge of the bed, leaning over the bedside table, allowing the fluid to collect in a dependent body area. If the client is unable to sit up, the nurse turns the client to the unaffected side and elevates the head of the bed 30 to 45 degrees. Turning to the affected side, the prone, and the Sims' positions are unsuitable positions for this procedure because these do not facilitate fluid removal.
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When planning the discharge of a client with a diagnosis of chronic anxiety, the nurse develops goals to promote a safe environment at home. Which topic is an appropriate maintenance goal for the client to focus on?
- A. Identifying anxiety-producing situations
- B. Maintaining contact with a crisis counselor
- C. Techniques for ignoring feelings of anxiety
- D. Eliminating all anxiety from daily situations
Correct Answer: A
Rationale: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations. Additionally, this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. It is impossible to eliminate all anxiety from life.
The nurse manager is observing the interaction between a new staff nurse and a client currently receiving hemodialysis. Which intervention should the nurse manager implement when the nurse and client are both drinking coffee and discussing the client's feeling about the procedure?
- A. Getting a cup of coffee and join in on the conversation
- B. Determining whether or not the client should be drinking coffee
- C. Complementing the staff nurse on the development of a good therapeutic relation
- D. Asking the staff nurse to refrain from eating and drinking in the hemodialysis area
Correct Answer: D
Rationale: The nurse manager should ask the second nurse to stop eating and drinking in the client area. A potential complication of hemodialysis is the acquisition of dialysis-associated hepatitis B. This is a concern for clients (who may carry the virus), client families (at risk from contact with the client and with environmental surfaces), and staff (who may acquire the virus from contact with the client's blood). This risk is minimized by the use of standard precautions; appropriate hand-washing and sterilization procedures; and the prohibition of eating, drinking, or other hand-to-mouth activity in the hemodialysis unit. None of the remaining options relate to management of this potential complication.
A client has a prescription for valproic acid 250 mg once daily. To maximize the client's safety, which time is best for the nurse to schedule administration of the medication?
- A. With lunch
- B. With breakfast
- C. Before breakfast
- D. At bedtime with a snack
Correct Answer: D
Rationale: Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side and adverse effects include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. Otherwise, it may be given after meals to avoid gastrointestinal upset.
Which client should the nurse safely assign to the unlicensed assistive personnel (UAP)?
- A. A client requiring dressing changes
- B. A client requiring frequent ambulation
- C. A client on a bowel management program requiring rectal suppositories
- D. A client newly admitted with nausea, vomiting, and moderate neck pain
Correct Answer: B
Rationale: Assignment of tasks to UAP needs to be made based on job description, level of clinical competence, and state law. The client described in option 2 has needs, frequent ambulation, that can be met by UAP. Options 1, 3, and 4 involve care that requires the skill of a licensed nurse.
The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement surgery. Which action is most appropriate for the nurse to plan to implement to protect the knee joint?
- A. Applying both ice and a compression dressing to the knee while sitting.
- B. Obtaining a walker to minimize weight-bearing by the client on the affected leg.
- C. First applying a knee immobilizer and then elevating the affect leg while sitting.
- D. Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place.
Correct Answer: C
Rationale: After a total knee replacement, as prescribed, the nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint to provide stability. The leg is elevated while the client is sitting in the chair to minimize edema. A compression dressing should already be in place on the wound. Ice is not used unless prescribed. The surgeon prescribes the weight-bearing limits on the affected leg. A CPM machine is used only while the client is in bed and is initiated when prescribed.