In assisting a physician to perform a thoracentesis to Mr. Sy, how should the nurse postion a patient with pleural effusion of the left lung?

Correct Answer: B

Rationale: The correct answer is B: sitting at the side of the bed with both arms resting on a locked overbed table. This position allows for better lung expansion and easier access to the thoracic cavity during the procedure. Sitting position helps in maximizing lung volume and facilitates drainage of pleural effusion. Arms resting on a locked overbed table helps the patient maintain a stable position and reduces the risk of movement during the procedure. Other choices are incorrect because supine position (A) may not allow for optimal lung expansion, high fowler's position (C) may not provide easy access to the thoracic cavity, and semi-fowlers position (D) may not facilitate efficient drainage of pleural effusion.

Correct Answer: C

Rationale: The correct answer is C: An intravenous set-up. Checking for an intravenous set-up is crucial to ensure that Mrs. Zeno is receiving necessary medications or fluids. It allows the nurse to monitor the infusion rate, prevent potential complications like infiltration, and ensure proper medication administration. A tracheostomy set (A) may be important for respiratory support but not essential for immediate safety. A hypothermia blanket (B) is used for temperature management and not directly related to Mrs. Zeno's immediate safety. A syringe and edrophonium HCl (D) are specific to a diagnostic test for myasthenia gravis and not necessary for general bedside safety assessment.

Correct Answer: C

Rationale: The correct answer is C: Etiology of the problem. In a nursing diagnosis statement, the etiology describes the underlying cause or contributing factors to the identified problem. This is crucial as it guides the selection of appropriate nursing interventions aimed at addressing the root cause of the issue. By addressing the etiology, nurses can implement interventions that will effectively treat the problem. Choice A (Problem statement) simply identifies the issue without providing insight into its cause. Choice B (Defining characteristics) lists the signs and symptoms of the problem but doesn't directly inform the interventions needed. Choice D (Outcomes criteria) outlines the expected results of the interventions but doesn't directly suggest which interventions to implement. Thus, C is the correct choice as it directly influences the selection of appropriate nursing interventions.

Correct Answer: A

Rationale: The correct answer is A: Provide the patient with a writing board each shift. This intervention addresses the impaired verbal communication by offering an alternative way for the patient to communicate. Writing board enables the patient to express thoughts and feelings, reducing the risk of loneliness. Choice B doesn't directly address the communication issue. Choice C is not relevant to the nursing diagnosis. Choice D, while promoting companionship, doesn't address the specific communication concern stated in the diagnosis.

Correct Answer: A

Rationale: The correct answer is A because bodily fluids and excretions (urine, feces, vomitus) can become contaminated with radiation from the implant. Therefore, they should be considered highly radioactive and handled appropriately. Choice B is incorrect because the client may remain radioactive for a longer period than 10 days post-implant removal. Choice C is incorrect because soiled linens should be handled according to radiation safety protocols and removed promptly. Choice D is incorrect because bed rest is not necessary unless specifically indicated by the healthcare provider; the client should be encouraged to move around as tolerated to prevent complications.

Correct Answer: A

Rationale: The correct answer is A: "Would you like to talk to a psychologist about your thoughts and feelings?" This response acknowledges the client's emotional distress and offers professional support. A psychologist can provide counseling and help the client explore their feelings and concerns about end-of-life decisions. Choice B is incorrect because it assumes the client's spiritual beliefs are the primary concern, neglecting the emotional and psychological aspects. Choice C involves more people in the decision-making process without addressing the client's individual needs. Choice D is dismissive and does not offer any support or explore the client's feelings further. In summary, choice A is the best response because it prioritizes the client's emotional well-being and offers appropriate support through professional counseling.

Correct Answer: B

Rationale: The correct answer is B because in a normal Rinne test, air conduction is heard longer than bone conduction in both ears. This is due to the fact that air conduction involves the transmission of sound waves through the external auditory canal, middle ear, and inner ear, which is more efficient than bone conduction where the sound waves are transmitted directly to the inner ear through the bones of the skull. Therefore, when the tuning fork is placed on the mastoid bone (bone conduction) and then moved next to the ear (air conduction), the sound should be heard longer through air conduction. Choice A is incorrect because normal auditory acuity does not necessarily mean equal perception in both ears. Choice C is incorrect as bone conduction should be heard shorter than air conduction in a normal Rinne test. Choice D is incorrect as the test does not determine which ear perceives sound better, but rather the difference in duration between air and bone conduction.

Correct Answer: A

Rationale: The correct answer is A. Before administering a narcotic analgesic like Morphine, assessing the client's level of alertness and respiratory rate is crucial to ensure they can tolerate the medication without compromising their breathing. Alertness indicates their ability to handle potential side effects, while respiratory rate is vital to monitor for any signs of respiratory depression. Choice B (last meal) is not directly related to giving a narcotic analgesic, although it may impact the absorption rate. Choice C (bowel habits) and last bowel movement are not immediately relevant to assessing the client's readiness for a narcotic analgesic. Choice D (history of addictions) is important but not the priority when assessing for immediate safety and efficacy of the medication.

Correct Answer: A

Rationale: The correct answer is A because the nurse is using data validation by comparing the time of the last dressing change with the appearance of old and new drainage. This process ensures that the decision to remove the wound dressing is based on accurate and relevant information. By assessing both the time of the last dressing change and the characteristics of the drainage, the nurse is validating the need for the intervention. Option B is incorrect because administering pain medicine based solely on a patient's report of increased pain without further validation does not demonstrate data validation. Option C is incorrect as the nurse immediately requesting an order of potassium without further assessment of the patient's condition is not an example of data validation. Option D is incorrect as elevating a leg cast based solely on a patient's report of decreased mobility without further assessment does not involve data validation.