A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention?
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Solution
Raised 30 degrees
Option C: Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30 degrees.
Options B and D: Increased pressure can’t be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible).
Option A: In high Fowler’s position, the veins would be barely discernible above the clavicle.
Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is:
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Solution
Beta-adrenergic blockers
Option A: Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infraction by decreasing myocardial oxygen demand.
Option B: Calcium channel blockers reduce the workload of the heart by decreasing the heart rate.
Option C: Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety.
Option D: Nitrates reduce myocardial oxygen consumption but decrease left ventricular end-diastolic pressure (preload) and systemic vascular resistance (afterload).
Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?
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Solution
In long, even, outward, and downward strokes in the direction of hair growth
Option C: When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.
Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:
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Solution
Turn him frequently.
Option A: The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn’t relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation.
Option B: During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers.
Option C: Adequate hydration is necessary to maintain healthy skin and ensure tissue repair.
Option D: A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.
Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
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Solution
Urine output of 20 ml/hour.
Option B: A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit.
Option A: This client’s PaO2 value falls within the normal range (80 to 100 mm Hg).
Option C: White pulmonary secretions also are normal.
Option D: The client’s rectal temperature isn’t significantly elevated and probably results from the fluid volume deficit.
Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?
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Solution
Applying knee splints
Option A: Applying knee splints prevents leg contractures by holding the joints in a position of function.
Option B: Elevating the foot of the bed can’t prevent contractures because this action doesn’t hold the joints in a position of function.
Option C: Hyperextending a body part for an extended time is inappropriate because it can cause contractures.
Option D: Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.
A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client’s stoma appears dusky. How should the nurse interpret this finding?
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Solution
Blood supply to the stoma has been interrupted
Option A: An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from interruption of the stoma’s blood supply and may lead to tissue damage or necrosis.
Option B: A dusky stoma isn’t a normal finding.
Option C: Adjusting the ostomy bag wouldn’t affect stoma color, which depends on blood supply to the area.
Option D: An intestinal obstruction also wouldn’t change stoma color.
Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially?
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Solution
Lying on the left side with knees bent
Option B: For a colonoscopy, the nurse initially should position the client on the left side with knees bent.
Option A, C, and D: Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn’t allow proper visualization of the large intestine.
A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
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Solution
Auscultate bowel sounds.
Option A: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician.
Option B: Palpation should be avoided postoperatively with abdominal distention.
Options C and D: If peristalsis is absent, changing positions and inserting a rectal tube won’t relieve the client’s discomfort.
Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?
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Solution
To prevent cerebrospinal fluid (CSF) leakage
Option C: The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution.
Options A, B, and D: Proper positioning doesn’t help prevent confusion, seizures, or cardiac arrhythmias.