MEDICAL AS NRSG 1136 Adult Health - Saunders Review Questions and Answer and Rationale,100% CORRECT
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MEDICAL AS NRSG 1136 Adult Health
MEDICAL AS NRSG 1136 Adult Health - Saunders Review Questions and Answer and Rationale
After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understands that the purpose of this intervention is to accomplish which?
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MEDICAL AS NRSG 1136 Adult Health - Saunders Review
Questions and Answer and Rationale
After a client undergoes a liver biopsy, the nurse places the client in the
prescribed right-side lying position. The nurse understands that the purpose of this
intervention is to accomplish which?
Limit bleeding from the biopsy site
Rationale:
After a liver biopsy, the client is assisted with assuming a right side-lying
position with a small pillow or folded towel under the puncture site for at least 3
hours to apply pressure and limit bleeding from the biopsy site. The liver
produces bile that flows through the common bile duct; client discomfort may be
decreased; and the liver does store glucose as glycogen, but this is not the purpose
of the right side-lying position.
The nurse is assisting with the insertion of a nasogastric tube into a client. The
nurse should place the client in which position for insertion?
High-Fowler's position
Rationale:
Before insertion of a nasogastric tube the nurse places the client in a sitting or high-
Fowler's position to reduce the risk of pulmonary aspiration if the client should
vomit. A pillow may be placed behind the head and shoulders to promote the client's
ability to swallow during procedure. Options 1, 2, and 4 do not facilitate the
insertion of the tube or prevent aspiration.
The nurse has inserted a nasogastric (NG) tube in a client and is checking for the
correct placement of an NG tube. Which is the most reliable data to ensure that
the end of the tube is in the stomach?
Placement is verified on x-ray.
Rationale:
The end of the NG tube should be in the stomach. An x-ray is the most reliable
method of determining correct placement. The radiologist may recommend
moving the tube backward or forward for a preferable placement. A low pH such
as 4.5 of the fluid aspirated is likely to be from the stomach, but pH is affected by
tube feeding formulas and prescribed proton-pump inhibitors. The characteristic
bile green is highly suggestive that the tube is in the stomach.
,Auscultation of the air injection is not recommended as a reliable method to
establish correct placement.
,A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN)
with removing a nasogastric (NG) tube from the client. Which interventions
should be included in the procedure? Select all that apply.
2. Explain the procedure to the client.
3. Ask the client to take a deep breath and hold.
4. Pull the tube out in one continuous steady motion.
5. Remove the device or tape securing the tube from the nose.
Rationale:
Before removing the tube, the client should be told about the procedure and review
the instructions. The tape or securing device needs to be removed from the client's
nose. When the NG tube is removed, the client is instructed to take and hold a deep
breath. This will close the epiglottis, and the airway will be temporarily obstructed
during the tube removal. This allows for the easy withdrawal of the tube through
the esophagus into the nose. The tube is removed with one very smooth,
continuous pull. There is no balloon that needs to be deflated on an NG tube.
An adult client was burned as a result of an explosion. The burn initially affected
the client's entire face (the anterior half of the head) and the upper half of the
anterior torso, and there were circumferential burns to the lower half of both arms.
The client's clothes caught on fire and the client ran, which caused subsequent
burn injuries of the posterior surface of the head and the upper half of the
posterior torso. According to the rule of nines, what is the extent of this client's
burn injury? Fill in the blank.
Correct Answer: 36 %
Rationale:
According to the rule of nines, with the initial burn, the anterior half of the head
equals 4.5%, the upper half of the anterior torso equals 9%, and the lower halves of
both arms equal 9%. The subsequent burn included the posterior half of the head,
which equals 4.5%, and the upper half of the posterior torso, which equals 9%. This
totals 36%.
A client returns to the clinic for follow-up treatment after a skin biopsy of a
suspicious lesion that was performed 1 week ago. The biopsy report indicates that
the lesion is a melanoma. The nurse understands that which characteristics describe
this type of a lesion? Select all that apply.
3. It is highly metastatic.
, 5. Lesion is a nevus that has changed in color.
Rationale:
Melanomas are pigmented malignant lesions that originate in the melanin-
producing cells of the epidermis. The lesion is a nevus that changes in color. This
skin cancer is highly metastatic and a person's survival depends on early diagnosis
and treatment. Basal cell carcinomas arise in the
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