A nurse is assisting a physician performing a liver biopsy. A nurse places the client in which of the following most appropriate position following the procedure?
a. Supine
b. Prone
c. At right side-lying position with a small pillow or folded towel under the puncture site
d. At the left side-lying position with a small pillow or folded towel under the puncture site
ANSWER: C
RATIONALE: After liver biopsy, the client is assisted to assume right side-lying position with a small pillow or folded towel because it compresses the liver against the chest wall at the biopsy site.
An anxious client comes to the Emergency Department with chief complaint of pain on the left side of his chest. A chest X-ray examination reveals a left pneumothorax. When assessing the left side of the client’s chest, the nurse would expect to find:
a. a vocal fremitus on palpation
b. a dull sound on percussion
c. an absence of breath sounds on auscultation
d. rales and rhonchi on auscultation
ANSWER: C
RATIONALE: The lung is collapsed; therefore, there are no breath sounds during auscultation.
A nurse is inserting an indwelling urinary catheter into a male client. The client complains of pain as the nurse inflates the balloon with a syringe. The nurse does which of the following:
a. aspirates the fluid from the balloon, advances the catheter farther then reinflates the balloon
b. removes the syringe from the balloon because discomfort is normal and temporary
c. aspirates the fluid from the balloon, waits until the discomfort subsides, then reinflates the balloon
d. aspirates the fluid from the balloon, removes the catheter, reinsert a new catheter
ANSWER: A
RATIONALE: If the balloon is positioned in the urethra, inflating the balloon could produce trauma, and pain will occur. If pain occurs, the fluid should be aspirated and the catheter inserted a little further in order to provide sufficient space to inflate the balloon.
A female client is admitted to the hospital, before performing a venipuncture to the client to initiate continuous intravenous (IV) therapy, a nurse should :
a. place a cool compress over the vein
b. Apply a tourniquet below the chosen vein site
c. Inspect the IV solution for particles or contamination
d. Secure an arm board to the joint located above the IV site
ANSWER: C
RATIONALE: All IV solutions should be free of particles or precipitates. The nurse must check the solution before the procedure.
A client comes to the clinic for a check up and suspected of having Tuberculosis. The nurse understands the most accurate method for confirming the diagnosis is:
a. obtaining client’s health history
b. a positive Purified Protein Derivative Test (PPD)
c. a chest X-ray positive for lung lesion
d. a sputum culture positive for Mycobacterium Tuberculosis
ANSWER: D
RATIONALE: The most accurate means of confirming the diagnosis of Tuberculosis is by sputum culture.
A nurse is assessing a client who had a Miller-Abbott tube in place for 24 hours, which assessed finding indicates that the tube is located in the intestines?
a. bowel sounds are absent
b. the client is nauseous
c. aspirate from the tube has a pH of 7
d. abdominal X-ray reveals that the tube is above the pylorus
ANSWER:C
RATIONALE: The Miller-Abbott tube is a nasogasenteric tube that is used to decompresses the intestine and to correct a bowel obstruction.
A physician tells the nurse to obtain a 24-hour urine collection to a client with renal problem. The nurse avoids which of the following to ensure proper collection of the 24-hour specimen.
a. discard the first voiding and save all subsequent voiding during the 24 hour time period
b. have the client void at the end time and place this specimen in the container
c. place the container on ice, or inside a refrigerator
d. have the client void at the start time, and place this specimen in the container
ANSWER: D
RATIONALE: The nurse asks the client to void at the beginning of the collection period and discard the unit sample.
A client is admitted to the hospital with a diagnosis of left pneumothorax by chest X-ray. The client is complaining of difficulty in breathing. Which of the following observed by the nurse indicates that the pneumothorax is rapidly worsening?
a. pain with respiration
b. Hypertension
c. Tracheal deviation to the right
d. Tracheal deviation to the left
ANSWER: C
RATIONALE: A pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), and subcutaneous emphysema, tracheal deviation to the unaffected side, decreased fremitus, and worsening cyanosis.
A nurse is caring for a client who is suspected of having a pleural effusion. The nurse assesses the client, knowing that a typical manifestation of this respiratory problem is :
a. Dyspnea on exertion and moist, productive cough
b. Dyspnea at rest and moist, productive cough
c. Dyspnea on exertion and dry, nonproductive cough
d. Dyspnea at rest and dry, nonproductive cough
ANSWER: C
RATIONALE: Typical assessment findings in the client with a pleural effusion include Dyspnea, which usually occurs with exertion, and a dry nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift.
A physician ordered to administer Apmhotericin B (Fungizone) intravenously to the client diagnosed with histoplasmosis. The nurse plans to do which of the following during administration of the medication?
a. assess the intravenous infusion site
b. monitor for hypothermia
c. monitor for an excessive urine output
d. administer a concurrent fluid challenge
ANSWER: A
RATIONALE: Apmhotericin B is a toxic medication, which can produce symptoms during administration such as chills, fever, headache, vomiting, and impaired renal function. The medication is very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications.
