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1. A healthcare provider is reviewing the medical record of a client who is scheduled for an abdominal paracentesis. Which of the following actions should the healthcare provider take to prepare the client for this procedure?
- A. Assist the client to void
- B. Instruct the client to hold their breath
- C. Place the client in a lateral recumbent position
- D. Prepare to administer a sedative
Correct answer: A
Rationale: Assisting the client to void before a paracentesis is essential to reduce the risk of bladder injury during the procedure. Voiding helps empty the bladder, preventing accidental puncture during the insertion of the needle. Instructing the client to hold their breath is incorrect and can increase the risk of complications. Placing the client in a lateral recumbent position is not directly related to bladder safety during a paracentesis. Preparing to administer a sedative is not a standard preparation for this procedure and is not aimed at preventing bladder injury.
2. What is the priority for the nurse when caring for a patient with a chest tube?
- A. Ensure tube patency and observe for air leaks
- B. Maintain sterile technique during dressing changes
- C. Monitor drainage and record output
- D. Observe for signs of infection and monitor for subcutaneous emphysema
Correct answer: A
Rationale: The priority for the nurse when caring for a patient with a chest tube is to ensure tube patency and observe for air leaks. This is essential to prevent complications such as pneumothorax and ensure the patient's lung function. While maintaining sterile technique during dressing changes, monitoring drainage, recording output, and observing for signs of infection and subcutaneous emphysema are also important, ensuring tube patency takes precedence as it directly impacts the patient's respiratory status and overall safety.
3. A nurse is teaching a client who has gastroesophageal reflux disease (GERD) about ways to reduce symptoms. Which of the following instructions should the nurse include?
- A. Avoid lying down after meals
- B. Eat large meals to reduce acid production
- C. Drink carbonated beverages with meals
- D. Consume spicy foods to improve digestion
Correct answer: A
Rationale: The correct answer is A: 'Avoid lying down after meals.' This instruction is important for clients with GERD as it helps reduce reflux symptoms. Lying down after meals can worsen GERD symptoms by allowing stomach acid to flow back into the esophagus. Choice B is incorrect because eating large meals can actually increase acid production and exacerbate GERD symptoms. Choice C is incorrect as carbonated beverages can trigger acid reflux in individuals with GERD. Choice D is also incorrect because consuming spicy foods can irritate the esophagus and lead to increased reflux symptoms.
4. What are the complications of untreated DVT?
- A. Pulmonary embolism and stroke
- B. Infection and kidney failure
- C. Hypertension and vision loss
- D. Dehydration and electrolyte imbalance
Correct answer: A
Rationale: The correct answer is A: Pulmonary embolism and stroke. Untreated DVT can result in these serious complications, emphasizing the importance of timely intervention. Choices B, C, and D are incorrect because they do not represent common complications associated with untreated deep vein thrombosis. Infection and kidney failure, hypertension and vision loss, as well as dehydration and electrolyte imbalance are not typically direct consequences of untreated DVT.
5. What are the nursing interventions for a patient experiencing hypoglycemia?
- A. Administer glucose or dextrose and monitor blood sugar levels
- B. Monitor vital signs and provide a high-carbohydrate snack
- C. Monitor for sweating and confusion
- D. Provide insulin and assess for hyperglycemia
Correct answer: A
Rationale: The correct answer is A. Administering glucose or dextrose is a crucial nursing intervention for a patient experiencing hypoglycemia as it helps to quickly raise blood sugar levels. Monitoring blood sugar levels is essential to ensure that the patient's glucose levels normalize. Choice B is incorrect because providing a high-carbohydrate snack may not be sufficient to rapidly raise blood sugar levels in severe hypoglycemia. Choice C is incorrect because while monitoring for sweating and confusion is important in hypoglycemia, it is not a direct nursing intervention. Choice D is incorrect as providing insulin would lower blood sugar levels further, worsening hypoglycemia.
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