Nursing Elites

1. What is the preferred position for a client post liver biopsy procedure?

• A. Fowler's
• B. Right side
• C. Left side
• D. Prone

Correct answer: B

Rationale: The correct position for a client post liver biopsy procedure is the right side. Placing the client on the right side helps apply pressure to the liver area, which can help in holding pressure and stopping bleeding. Placing the client on the left side may not be as effective in providing direct pressure on the liver. The prone position is also not ideal for post-liver biopsy care as it does not target the liver area directly. Fowler's position, a semi-sitting position, is not typically recommended post liver biopsy as it does not provide the necessary pressure on the liver site.

2. A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?

• A. temperature of 102�F and a productive cough
• B. arterial blood gases (ABGs) with a PaO2 of 92 mmHg and PaCO2 of 40 mmHg
• C. trachea deviating to the right
• D. barrel-chested appearance

Correct answer: C

Rationale: The correct answer is 'trachea deviating to the right.' A mediastinal shift is indicative of a tension pneumothorax, which is a dangerous complication seen in trauma patients with symptoms like crepitus, decreased breath sounds, shortness of breath, and tachypnea. Assessing for acute traumatic injuries is crucial in this context. Choice A, a temperature of 102�F and a productive cough, is common in pneumonia cases and not as concerning as a mediastinal shift. Choice B, ABGs with a PaO2 of 92 mmHg and PaCO2 of 40 mmHg, shows values within normal limits and does not suggest a tension pneumothorax. Choice D, a barrel-chested appearance, is typical of COPD and not directly related to the acute traumatic injury described. A tension pneumothorax is a medical emergency where air cannot escape the pleural cavity, leading to lung collapse and a mediastinal shift to the unaffected side with a downward displacement of the diaphragm.

3. When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing:

• A. one commercially prepared glucose tablet
• B. two hard candies
• C. 4-6 ounces of fruit juice
• D. 2-3 teaspoons of honey

Correct answer: D

Rationale: The correct immediate intervention for hypoglycemia is to provide 10-15 grams of fast-acting simple carbohydrates orally if the client is conscious and able to swallow. This can be achieved by giving 2-3 teaspoons of honey. Honey is a quick source of simple sugars that can rapidly raise blood glucose levels. Commercially prepared glucose tablets or 4-6 ounces of fruit juice are also appropriate options. However, adding sugar to fruit juice is unnecessary as the natural fruit sugar in juice already provides enough simple carbohydrates to raise blood glucose levels. Hard candies are not the best choice for immediate intervention in hypoglycemia as they may not provide a sufficient amount of fast-acting carbohydrates needed to raise blood sugar levels quickly.

4. What is the priority nursing action for a laboring client dilated to 6 cm receiving an epidural?

• A. Continuous monitoring of maternal blood pressure.
• B. Frequent auscultation of the fetal heart rate.
• C. Administering an IV fluid bolus of at least 500 cc.
• D. Frequent monitoring of the maternal temperature.

Correct answer: A

Rationale: The priority nursing action for a laboring client dilated to 6 cm receiving an epidural is continuous monitoring of maternal blood pressure. This is crucial because epidural anesthesia can lead to a precipitous drop in blood pressure, which can be dangerous for both the mother and fetus by reducing cardiac output and placental perfusion. While frequent auscultation of the fetal heart rate is important, it is not the priority in this situation. Administering an IV fluid bolus of at least 500 cc may not be necessary if the client's blood pressure is stable. Monitoring the maternal temperature is also essential but takes precedence over blood pressure monitoring.

5. If a client is suffering from thyroid storm, the PN can expect to find on assessment:

• A. tachycardia and hyperthermia.
• B. bradycardia and hypothermia.
• C. a large goiter.
• D. a calm, quiet client

Correct answer: A

Rationale: In thyroid storm, there is an excess of thyroxine, leading to symptoms such as tachycardia (rapid heart rate) and hyperthermia (increased body temperature). Atrial fibrillation and palpitations are also commonly observed. Choices B and C are more indicative of hypothyroidism, where the thyroid is underactive, leading to bradycardia (slow heart rate), hypothermia (decreased body temperature), and the development of a large goiter. Choice D, a calm, quiet client, is unlikely in a thyroid storm where the individual would typically present with symptoms of agitation and restlessness due to the hypermetabolic state.

Similar Questions