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Questions 149

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Question 1 of 5

The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:

Correct Answer: A

Rationale: Providing a urinal allows the client to empty their bladder, reducing the risk of bladder puncture during paracentesis.

Question 2 of 5

The nurse has inserted an NG tube for enteral feedings. Which assessment result is the best indicator of the tube's stomach placement?

Correct Answer: B

Rationale: A green aspirate with a pH of 3 confirms gastric placement, as stomach contents are acidic and often green due to bile, providing the most reliable indicator.

Question 3 of 5

A client has been instructed in the application and use of anti-embolic compression stockings. Which of the following statements by the client indicates a need for more teaching? Select all that apply.

Correct Answer: A,B,D

Rationale: Rolling the top down (
A) can impede circulation, removing stockings every 1-2 days (
B) is too infrequent (should be every 8 hours), and baby powder (
D) can cause skin irritation. Turning the stocking inside out (
C) and preventing clots (E) are correct.

Question 4 of 5

The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports, which client should be seen first?

Correct Answer: C

Rationale: Edema and neck vein distention in a bronchitis client suggest heart failure, a critical condition requiring immediate assessment. The other clients are stable or less urgent.

Question 5 of 5

A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:

Correct Answer: C

Rationale: A viral load of 200 copies/ml is low, indicating effective treatment and minimal circulating virus.

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