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?

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Question 1 of 9

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.

Question 2 of 9

What is the focus of a diagnostic statement for a collaborative problem?

Correct Answer: B

Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying any potential complications that may arise due to the client's condition or treatment. This allows nurses and other healthcare professionals to anticipate and address these complications proactively. A: The client problem - While important, the client problem is usually addressed in the nursing diagnosis rather than the diagnostic statement for a collaborative problem. C: The nursing diagnosis - The nursing diagnosis focuses on the actual or potential health problems that the client is experiencing, which is different from the focus of a diagnostic statement for a collaborative problem. D: The medical diagnosis - The medical diagnosis is the identification of a disease or condition by a healthcare provider, which is not the focus when identifying potential complications in a collaborative problem.

Question 3 of 9

The nurse is reviewing the medication history of a new preoperative patient who is nil by mouth (NPO). The nurse notes that the patient has been on long-term oral steroid therapy. The nurse understands that which of the following is the reason that steroids cannot be abruptly stopped?

Correct Answer: A

Rationale: The correct answer is A because abruptly stopping steroids can lead to adrenal insufficiency due to suppression of the adrenal glands. This can result in a sudden drop in cortisol levels, which are essential for various physiological functions. Patients on long-term steroid therapy need a gradual taper to allow the adrenal glands to resume cortisol production. Choices B, C, and D are incorrect as they do not directly relate to the physiological effects of stopping steroids abruptly.

Question 4 of 9

The most significant form of meningitis is:

Correct Answer: A

Rationale: The correct answer is A: Bacterial meningitis. Bacterial meningitis is the most significant form due to its potential severity and rapid progression, requiring urgent medical intervention with antibiotics. Bacterial meningitis can lead to serious complications such as brain damage or death if left untreated. Septic meningitis (choice B) refers to meningitis caused by a systemic infection spreading to the meninges. Aseptic meningitis (choice C) is typically viral or non-bacterial in origin, usually milder than bacterial meningitis. Viral meningitis (choice D) is less severe than bacterial meningitis and often resolves on its own without specific treatment.

Question 5 of 9

How can the nurse help monitor effectiveness of therapy for the patient with a pneumothorax and chest-drainage system?

Correct Answer: C

Rationale: The correct answer is C: Auscultate lung sounds. By auscultating lung sounds, the nurse can assess for changes in breath sounds which can indicate improvement or deterioration in the patient's condition. This helps monitor the effectiveness of therapy for a pneumothorax and chest-drainage system. Palpating for crepitus (A) is not directly related to monitoring therapy effectiveness. Documenting sputum color and amount (B) is important but does not specifically monitor therapy effectiveness. Monitoring suction level (D) is crucial but does not directly assess the patient's response to therapy.

Question 6 of 9

To provide safe care for Mrs. Zeno, it is important for the nurse to check the bedside for the presence of:

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.

Question 7 of 9

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.

Question 8 of 9

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient’s care plan?

Correct Answer: C

Rationale: The correct nursing diagnosis is C: Impaired skin integrity. This choice is correct because it directly addresses the bacterial infection in the left lower leg by focusing on the skin's condition. The patient's skin integrity is compromised due to the infection, making this nursing diagnosis appropriate. Choice A (Infection) is too broad and does not specify the impact on the skin. Choice B (Risk for infection) is incorrect because the patient already has a bacterial infection, so the risk has already manifested. Choice D (Staphylococcal leg infection) is too specific and does not address the broader issue of skin integrity. Therefore, the best choice is C as it accurately reflects the patient's current condition and guides appropriate nursing interventions to address the impaired skin integrity caused by the bacterial infection.

Question 9 of 9

A patient is admitted for a splenectomy. Why is an injection of Vit. K ordered before surgery?

Correct Answer: A

Rationale: Step 1: Vitamin K is essential for the synthesis of clotting factors in the liver. Step 2: A splenectomy increases the risk of bleeding due to decreased platelet sequestration. Step 3: Preoperative Vitamin K injection helps correct any clotting deficiencies. Summary: - Choice B is incorrect as Vitamin K does not prevent infection. - Choice C is incorrect as Vitamin K does not directly promote healing. - Choice D is incorrect as Vitamin K does not dry secretions.

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