Question

A nurse is assisting a provider with a client who is to undergo a thoracentesis. In which of the following positions should the nurse place the client?

Answer 1

Correct Answers:

Sitting upright while leaning forward over pillows

Rationale :

💎 For thoracentesis, sitting upright allows the pleural space to be more accessible for needle insertion.

💎 Leaning forward over pillows helps spread the intercostal spaces, reducing the risk of puncturing the lung.

💎 Lying prone, Trendelenburg, or supine positions do not provide optimal access and may increase procedural risk.

💎 Proper positioning improves safety and effectiveness of the procedure.

💎 Nurses assist with positioning and monitor vital signs during the procedure.

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Answer 2

Correct Answers:

"I'll hold my cell phone against the ear on the opposite side of my body."

Rationale :

🔹 Clients with a permanent pacemaker should keep electronic devices, including cell phones, away from the generator site to prevent interference.

🔹 MRIs are generally contraindicated unless the pacemaker is MRI-compatible; CAT scans are safe.

🔹 Microwave ovens do not interfere with modern pacemakers.

🔹 Air travel through security is generally safe; clients should carry pacemaker ID cards.

🔹 Patient education focuses on device safety and minimizing electromagnetic interference.

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Answer 3

Correct Answers:

Check the client for ecchymosis

Rationale :

🔹 Thrombocytopenia increases bleeding risk, so nurses should assess for ecchymosis, petechiae, and bleeding.

🔹 Shaving with disposable razors is acceptable but secondary to bleeding assessment.

🔹 Protective isolation is not routinely required unless neutropenic.

🔹 Ibuprofen should be avoided as it inhibits platelet function and increases bleeding risk.

🔹 Early recognition of bleeding manifestations allows for prompt intervention.

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Answer 4

Correct Answers:

"I might have blood-tinged sputum after the procedure."

Rationale :

🔹 Bronchoscopy can cause minor trauma to the airway, resulting in blood-tinged sputum, which is expected.

🔹 Eating immediately post-procedure is unsafe until gag reflex returns.

🔹 No radioactive material is used routinely.

🔹 Clear liquids are usually restricted for several hours pre-procedure to reduce aspiration risk.

🔹 Nurses educate clients about expected post-procedure findings and safety precautions.

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Answer 5

Correct Answers:

"I will examine my breasts a week after each menstrual period."

Rationale :

🔹 Breast self-examination is best performed a few days after menstruation, when tissue is least swollen or tender.

🔹 The flu shot does not last 2 years; it is annual.

🔹 Hepatitis B vaccine is not given yearly; it is a primary series with booster if indicated.

🔹 Testicular self-exams should be performed monthly, not every 6 months.

🔹 Correct understanding reflects appropriate timing and frequency of health screenings.

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Answer 6

Correct Answers:

"I will wrap my affected ankle with an elastic bandage."

Rationale :

💎 For a grade 2 ankle sprain, wrapping the ankle with an elastic bandage provides support, reduces swelling, and limits further injury.

💎 Full weight-bearing is not recommended initially; partial or assisted weight-bearing is preferred.

💎 Dangling the ankle can increase swelling.

💎 Applying heat acutely may worsen inflammation; cold therapy is recommended first 24–48 hours.

💎 Education on proper RICE therapy (Rest, Ice, Compression, Elevation) promotes healing and prevents complications.

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Answer 7

Correct Answers:

Have the client wear a surgical mask during transport

Rationale :

🔹 Influenza is transmitted via respiratory droplets; having the client wear a surgical mask helps prevent spread during transport.

🔹 N95 masks are reserved for airborne pathogens, which is unnecessary for influenza.

🔹 Administering immunization is preventive, not therapeutic during active infection.

🔹 Negative airflow rooms are used for airborne precautions, not droplet precautions.

🔹 Proper infection control reduces nosocomial transmission.

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Answer 8

Correct Answers:

"Install grab bars in your shower to assist with your balance."

Rationale :

🔹 Clients post-CVA with ADL deficits benefit from environmental modifications like grab bars to prevent falls and improve safety.

🔹 Using assistive devices does not completely eliminate fatigue; this is unrealistic.

🔹 Placing a towel in the shower is insufficient and may increase slipping risk.

🔹 Hiring a home care aide for all ADLs is unnecessary if self-care is achievable with assistive devices.

🔹 Nurse education emphasizes fall prevention and independence in home care.

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Answer 9

Correct Answers:

A client who has a viral respiratory infection

Rationale :

🔹 Inner ear inflammation (otitis media or labyrinthitis) often follows viral upper respiratory infections, as pathogens can travel via the eustachian tube.

🔹 Tumors on the pituitary, ampicillin use, or H. pylori infection are not direct risk factors.

🔹 Recognizing at-risk clients allows nurses to monitor for vertigo, hearing loss, or balance issues.

🔹 Early identification aids in prompt management and symptom relief.

🔹 Patient education focuses on symptom reporting and follow-up care.

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Answer 10

Correct Answers:

3 oz ground beef

Rationale :

🔹 Ground beef is a rich source of heme iron, which is more readily absorbed than non-heme iron found in plant-based or other meats.

🔹 Tuna, chicken, and pork contain iron but in lower amounts per equivalent serving.

🔹 Adequate dietary iron helps correct iron-deficiency anemia and improve hemoglobin levels.

🔹 Nurses should educate clients on pairing iron-rich foods with vitamin C to enhance absorption.

🔹 Regular dietary intake supports long-term prevention and recovery from anemia.

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PN med surg 2023 ATI

No.

1 :
A nurse is assisting a provider with a client who is to undergo a thoracentesis. In which of the following positions should the nurse place the client?

2 :
A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?

4 :
A nurse is reinforcing teaching with a client who is scheduled to undergo a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?

5 :
A nurse is reinforcing health promotion education at a community health fair. Which of the following statements by attendees indicates understanding of the teaching?

6 :
A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?

7 :
A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?

8 :
A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?

9 :
A nurse is caring for four clients. Which of the following clients should the nurse identify as at risk for inner ear inflammation?

10 :
A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should instruct the client that which of the following foods has the highest iron content?

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PN med surg 2023 ATI

No.

1 : A nurse is assisting a provider with a client who is to undergo a thoracentesis. In which of the following positions should the nurse place the client?

2 : A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?

3 : A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?

4 : A nurse is reinforcing teaching with a client who is scheduled to undergo a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?

5 : A nurse is reinforcing health promotion education at a community health fair. Which of the following statements by attendees indicates understanding of the teaching?

6 : A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?

7 : A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?

8 : A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?

9 : A nurse is caring for four clients. Which of the following clients should the nurse identify as at risk for inner ear inflammation?

10 : A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should instruct the client that which of the following foods has the highest iron content?

1 :
A nurse is assisting a provider with a client who is to undergo a thoracentesis. In which of the following positions should the nurse place the client?

2 :
A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?

4 :
A nurse is reinforcing teaching with a client who is scheduled to undergo a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?

5 :
A nurse is reinforcing health promotion education at a community health fair. Which of the following statements by attendees indicates understanding of the teaching?

6 :
A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?

7 :
A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?

8 :
A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?

9 :
A nurse is caring for four clients. Which of the following clients should the nurse identify as at risk for inner ear inflammation?

10 :
A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should instruct the client that which of the following foods has the highest iron content?