A client has undergone gastrectomy. Nurse Jovy is aware that the best position for the client is:
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Solution
Low Fowler’s
Option B: A client who has had abdominal surgery is best placed in a low Fowler’s position. This relaxes abdominal muscles and provides maximum respiratory and cardiovascular function.
Nurse Jenny should caution a female client who is sexually active in taking Isoniazid (INH) because the drug has which of the following side effects?
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Solution
Decreases the effectiveness of oral contraceptives
Option C: Isoniazid (INH) interferes in the effectiveness of oral contraceptives and clients of childbearing age should be counseled to use an alternative form of birth control while taking this drug.
A client has undergone right pneumonectomy. When turning the client, the nurse should plan to position the client either:
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Solution
Right side-lying position or supine
Option A: Right side-lying position or supine position permits ventilation of the remaining lung and prevent fluid from draining into sutured bronchial stump.
A hospitalized client had a tonic-clonic seizure while walking down the hall. During the seizure the nurse priority should be:
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Solution
Protects the client’s head from injury
Option D: Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated banging of head.
Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be most indicative sign of increasing intracranial pressure?
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Solution
Increased restlessness
Option D: Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.
A client who suffered from automobile accident complains of seeing frequent flashes of light. The nurse should expect:
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Solution
Detached retina
Option B: This symptom is caused by stimulation of retinal cells by ocular movement.
Nurse Carol is assessing a client with Parkinson’s disease. The nurse recognizes bradykinesia when the client exhibits:
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Solution
Lack of spontaneous movement
Option D: Bradykinesia is slowing down from the initiation and execution of movement.
A female client develops an infection at the catheter insertion site. The nurse in charge uses the term “iatrogenic” when describing the infection because it resulted from:
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Solution
Therapeutic procedure
Option B: Iatrogenic infection is caused by the health care provider or is induced inadvertently by medical treatment or procedures.
A nurse is planning to assess the corneal reflex on unconscious client. Which of the following is the safest stimulus to touch the client’s cornea?
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Solution
Wisp of cotton
Option D: A client who is unconscious is at greater risk for corneal abrasion. For this reason, the safest way to test the corneal reflex is by touching the cornea lightly with a wisp of cotton.