Nokea
Which of the following are correct nursing actions related to client positioning? Select all that apply.
- A. Position client in Fowler position after cardiac catheterization via femoral entry
- B. Position client in Trendelenburg position on the left side if air embolism is suspected
- C. Position client on the left side following a liver biopsy
- D. Position client on the side with head, back, and knees flexed during lumbar puncture
- E. Position client with the arm raised above the head for chest tube placement
Correct Answer: B,D,E
Rationale: Trendelenburg on the left traps air in the heart’s apex for air embolism, side-lying with flexion aids lumbar puncture access, and arm elevation facilitates chest tube placement. Fowler post-catheterization risks bleeding, and right side-lying is standard post-liver biopsy.
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Which of the following interventions is most helpful in determining the need for oxygen therapy for a client with COPD?
- A. Asking the client whether he needs $\mathrm{O}_2$
- B. Assessing the client's level of fatigue
- C. Evaluating the hemoglobin level
- D. Using a pulse oximeter on the client's ear lobe
Correct Answer: D
Rationale: Pulse oximetry objectively measures oxygen saturation, guiding the need for oxygen therapy in COPD. Subjective reports and hemoglobin levels are less direct.
The nurse is caring for a 45-year-old client with atrial fibrillation who has been receiving diltiazem. Which of the following findings would indicate that the medication has been effective?
- A. Blood pressure of 126/78 mm Hg
- B. Client does not have chest pain
- C. Client has not experienced any signs of stroke
- D. Ventricular rate decreased from 158/min to 88/min
Correct Answer: D
Rationale: Diltiazem is used in atrial fibrillation to control ventricular rate. A decrease from 158/min to 88/min indicates effective rate control. Blood pressure, chest pain, and stroke prevention are not primary indicators of diltiazem's efficacy in this context.
Which comment by the client is most significant in light of the fact that he has Ménière's disease?
- A. I take a walk every day.
- B. I listen to my iPOD a lot.
- C. I smoke a pack of cigarettes a day.
- D. It is very noisy at my workplace.
Correct Answer: C
Rationale: Cigarette smoking has been shown to aggravate Ménière's disease. The client will be told to stop smoking to decrease the frequency and severity of Ménière's. Walking, listening to an IPOD or other electronic device, and exposure to noise have not been shown to be related to Ménière's disease.
Which of the following individuals may legally give informed consent?
- A. an 86-year-old male with advanced Alzheimer's disease
- B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- C. a 72-year-old female scheduled for a heart transplant
- D. a 6-month-old baby needing bowel surgery
Correct Answer: C
Rationale: The 72-year-old female, presumed competent, can give informed consent. Those with advanced Alzheimer's, non-emancipated minors, and infants cannot legally consent. Coordinated Care
Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct Answer: B
Rationale: Quality care involves meeting or exceeding standards and expectations, not merely performing at a minimal level, which is insufficient for quality. Coordinated Care