Nokea
Which action should the nurse take before performing a venipuncture to initiate continuous intravenous (IV) therapy?
- A. Apply a cool compress to the affected area.
- B. Inspect the IV solution and expiration date.
- C. Secure a padded arm board above the IV site.
- D. Apply a tourniquet below the venipuncture site.
Correct Answer: B
Rationale: IV solutions should be free of particles or precipitates to prevent trauma to veins or a thromboembolic event; in addition, the nurse avoids administering IV solutions whose expiration date has passed to prevent infection. Cool compresses cause vasoconstriction, making the vein less visible, smaller, and more difficult to puncture. Arm boards are applied after the IV is started and are used only if necessary. A tourniquet is applied above the chosen vein site to halt venous return and engorge the vein; this makes the vein easier to puncture.
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A client is receiving desmopressin intranasally. Which assessment parameters should the nurse monitor to determine the effectiveness of this medication?
- A. Daily weight
- B. Temperature
- C. Apical heart rate
- D. Pupillary response
Correct Answer: A
Rationale: Desmopressin is an analog of vasopressin (antidiuretic hormone). It is used in the management of diabetes insipidus. The nurse monitors the client's fluid balance to determine the effectiveness of the medication. Fluid status can be evaluated by noting intake and urine output, daily weight, and the presence of edema. The measurements in options 2, 3, and 4 are not related to this medication.
The nurse is providing care for a client who has just experienced a liver biopsy performed at the bedside. Which position should the nurse place the client in after the biopsy?
- A. Supine with the head elevated on one pillow
- B. Semi-Fowler's with two pillows under the legs
- C. Left side-lying with a small pillow under the puncture site
- D. Right side-lying with a folded towel under the puncture site
Correct Answer: D
Rationale: The liver is located on the right side of the body. After a liver biopsy, the nurse positions the client on the right side with a small pillow or folded towel under the puncture site for 2 hours. This position compresses the liver against the abdominal wall at the biopsy site to tamponade bleeding from the puncture site.
A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On assessment, which manifestation related to the client's menstrual cycle should the nurse expect the client to report?
- A. Amenorrhea
- B. Menorrhagia
- C. Metrorrhagia
- D. Dysmenorrhea
Correct Answer: A
Rationale: Amenorrhea or a decreased menstrual flow is common in the client with Graves' disease. Menorrhagia, metrorrhagia, and dysmenorrhea are also disorders related to the female reproductive system; however, they do not manifest in the presence of Graves' disease.
The nurse is caring for a client who is scheduled to have a liver biopsy. Before the procedure, it is important for the nurse to assess which parameter to assure client safety?
- A. Tolerance for pain
- B. Allergy to iodine or shellfish
- C. History of nausea and vomiting
- D. Ability to lie still and hold the breath
Correct Answer: D
Rationale: A liver biopsy is an invasive procedure that involves inserting a needle into the liver to obtain a tissue sample. To ensure client safety, the nurse must assess the client's ability to lie still and hold their breath during the procedure, as movement or breathing can cause complications such as bleeding or injury to surrounding organs. Assessing pain tolerance, allergies to iodine or shellfish, or a history of nausea and vomiting is not directly related to the safety of the liver biopsy procedure.
A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply.
- A. Weight loss
- B. Bradycardia
- C. Hypotension
- D. Dry, scaly skin
- E. Heat intolerance
- F. Decreased body temperature
Correct Answer: B,C,D,F
Rationale: The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. Some of these manifestations are bradycardia; hypotension; cool, dry, scaly skin; decreased body temperature; dry, coarse, brittle hair; decreased hair growth; cold intolerance; slowing of intellectual functioning; lethargy; weight gain; and constipation.