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Supine with the head of bed elevated at a 45- to 60-
degree angle
When preparing a client Rationale:
for a pericardiocentesis, The client undergoing pericardiocentesis is
how does the nurse positioned supine with the head of bed elevated to a
position the client? 45- to 60-degree angle. This places the heart in
proximity to the chest wall for easier insertion of the
needle into the pericardial sac. The remaining options
are incorrect positions for this procedure.
A client with angina Variant angina
complains that the anginal
pain is prolonged and Rationale:
severe and occurs at the Variant angina, or Prinzmetal's angina, is prolonged
same time each day, most and severe and occurs at the same time each day,
often in the morning. On most often in the morning. Stable angina is induced
further data collection, the by exercise and relieved by rest or nitroglycerin
nurse notes that the pain tablets. Unstable angina occurs at lower and lower
occurs in the absence of levels of activity or at rest, is less predictable, and is
precipitating factors. This often a precursor of myocardial infarction.
type of anginal pain is
best described as:
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Hypotension
A nurse is caring for a
client after thyroidectomy Rationale:
and monitoring for signs Clinical manifestations associated with thyroid storm
of thyroid storm. The include a fever as high as 106° F (41.1° C), severe
nurse understands that tachycardia, profuse diarrhea, extreme vasodilation,
which of the following is a hypotension, atrial fibrillation, hyperreflexia,
manifestation associated abdominal pain, diarrhea, and dehydration. With this
with this disorder? disorder, the client's condition can rapidly progress to
coma and cardiovascular collapse.
Has a brownish or "brawny" appearance
Rationale:
A client is admitted to the
Venous leg ulcers, also called stasis ulcers, are
hospital with a venous
typically partial-thick wounds that extend through the
stasis leg ulcer. The nurse
epidermis and portions of the dermis. The skin of the
inspects the ulcer,
lower leg is leathery, with a characteristic brownish or
expecting to note that the
"brawny" appearance from the hemosiderin
ulcer:
deposition. The edges of the ulcer are irregular and
the tissue is a ruddy color. The client also may exhibit
peripheral edema.
Applying manual pressure over the site
A client who has had a
Rationale:
radical neck dissection
If the client begins to hemorrhage from the surgical
begins to hemorrhage at
site following radical neck dissection, the nurse
the incision site. Which
elevates the head of the bed to maintain airway
action by the nurse would
patency and prevent aspiration. The nurse applies
be contraindicated?
pressure over the bleeding site and calls the health
care provider immediately.
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The system is functioning as expected.
A nurse checks the water
seal chamber of a closed
Rationale:
chest drainage system and
Fluctuations in the water seal chamber are normal
notes fluctuations in the
during inhalation and exhalation until the lung re-
chamber. Based on this
expands and the client no longer requires chest
finding, the nurse
drainage. If fluctuations are absent, it could indicate
determines that:
an air leak, kinking, or that the lung has re-expanded.
An ambulatory clinic nurse "Does the pain get worse when you breathe in?"
is interviewing a client
who is complaining of flu- Rationale:
like symptoms. The client Chest pain is assessed using the standard pain
suddenly develops chest assessment parameters, (characteristics, location,
pain. Which question intensity, duration, precipitating and alleviating factors,
would best help the nurse and associated symptoms). Options 1, 2, and 4 may or
to discriminate pain may not help determine the origin of pain. Pain of
caused by a noncardiac pleuropulmonary origin usually worsens on
problem? inspiration.
Percuss the medial nerve at the wrist as it enters the
carpal tunnel, and monitor for tingling sensations.
A nurse is assisting in Rationale:
checking for Tinel's sign in The presence of Tinel's sign is determined by
a client suspected of percussing the medial nerve at the wrist as it enters
having carpal tunnel the carpal tunnel. A tingling sensation over the
syndrome (CTS). Which distribution of the nerve occurs in CTS. The presence
technique would the nurse of Phalen's sign is determined by asking the client to
expect to be used to elicit flex the wrist at a 90-degree angle for 1 minute.
this sign? Numbness and tingling over the distribution of the
median nerve, the palmar surface of the thumb, and
the index and middle fingers suggest CTS. Phalen's
sign is also an indication of CTS.
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