Nokea
To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis?
- A. Place flat in bed
- B. Turn on the affected side
- C. Turn on the unaffected side
- D. On bed rest SENSORY DISORDERS
Correct Answer: B
Rationale: The correct answer is B: Turn on the affected side. This position helps to promote the closure of the puncture site in the lung, reducing the risk of fluid leakage and pneumothorax. Placing the client flat in bed (A) may not allow gravity to assist in the closure of the puncture site. Turning on the unaffected side (C) may not effectively prevent fluid leakage from the puncture site. Bed rest (D) is a general instruction and does not specifically address the prevention of fluid leakage after thoracentesis.
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When caring for a client, whose being treated for hyperthyroidism, it’s important to:
- A. Provide extra blankets and clothing to keep the client warm.
- B. Monitor the client for signs of restlessness, sweating and excessive weight loss during thyroid replacement therapy.
- C. Balance the client’s periods of activity and rest.
- D. Encourage the client to be active to prevent constipation.
Correct Answer: B
Rationale: The correct answer is B. Monitoring for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy is essential in managing hyperthyroidism. Restlessness can indicate increased metabolic rate, sweating can be due to excessive heat production, and weight loss can be a sign of overactive thyroid function. Providing extra blankets (Choice A) may worsen symptoms of heat intolerance. Balancing activity and rest (Choice C) is important, but not specific to hyperthyroidism. Encouraging activity to prevent constipation (Choice D) is not directly related to managing hyperthyroidism.
A nurse teaches a client newly diagnosed with diabetes how to administer insulin. What type of nursing intervention is this?
- A. Independent intervention
- B. Dependent intervention
- C. Interdependent intervention
- D. Collaborative intervention
Correct Answer: A
Rationale: Correct Answer: A (Independent intervention)
Rationale:
1. Independent interventions are actions that nurses can initiate without a doctor's order.
2. Teaching a client how to administer insulin falls under the scope of nursing practice.
3. Nurses have the knowledge and authority to educate clients on self-care management.
4. This intervention does not require collaboration with other healthcare providers.
Summary:
B: Dependent interventions require a doctor's order.
C: Interdependent interventions involve collaboration with other healthcare providers.
D: Collaborative interventions involve working with other healthcare professionals.
During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
- A. Squamous cell carcinoma
- B. Leukemia
- C. Multiple myeloma
- D. Kaposi’s sarcoma
Correct Answer: D
Rationale: The correct answer is D: Kaposi’s sarcoma. In AIDS patients, Kaposi’s sarcoma is a common cancer caused by human herpesvirus 8. It presents as purple or brown skin lesions. Squamous cell carcinoma (A), leukemia (B), and multiple myeloma (C) are not commonly associated with AIDS. Squamous cell carcinoma is linked to sun exposure, leukemia originates in the bone marrow, and multiple myeloma is a cancer of plasma cells. Therefore, the correct answer is D due to its strong association with AIDS.
The nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
- A. The client lies still.
- B. The client wears a watch and wedding
- C. The client asks questions. band.
- D. the client hears thumping sounds.
Correct Answer: B
Rationale: The correct answer is B: The client wears a watch and wedding band. This is because metal objects such as watches and jewelry can be hazardous during an MRI scan due to the strong magnetic field, leading to potential movement or heating of the metal objects, causing harm to the client.
A: The client lies still - This is important for obtaining clear images during an MRI scan and does not pose a threat to the client.
C: The client asks questions - Asking questions during an MRI scan does not pose a direct threat to the client's safety.
D: The client hears thumping sounds - Thumping sounds are a normal part of the MRI scan and do not pose a threat to the client's safety.
During a routine check-up, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:
- A. Muscle weakness
- B. Painful subcutaneous nodules
- C. Joint abnormalities
- D. Gait disturbances
Correct Answer: C
Rationale: The correct answer is C: Joint abnormalities. In rheumatoid arthritis, joint abnormalities such as swelling, warmth, and tenderness are the hallmark manifestations. Assessing joint abnormalities first is crucial as they are the primary clinical signs of the disease. Muscle weakness (A) is a common symptom but typically occurs later due to joint inflammation and disuse. Painful subcutaneous nodules (B) are present in some cases but are not as common or prominent as joint abnormalities. Gait disturbances (D) may occur as a result of joint damage, but they are secondary to the primary manifestation of joint abnormalities. By prioritizing the assessment of joint abnormalities, the nurse can promptly identify and address the most prevalent disease manifestations in rheumatoid arthritis.