Nokea
A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to
- A. avoid intercourse for 48 hours before the examination.
- B. avoid douching for 24 hours prior to her appointment.
- C. withhold all foods and fluids 12 hours before the appointment.
- D. save her first voided urine specimen the morning of her appointment.
Correct Answer: B
Rationale: douching would affect appearance of cells in vaginal smear, would make test inaccurate
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The nurse is teaching a client about self-administration of insulin. Which of the following sites should the nurse recommend for insulin injection?
- A. Forearm.
- B. Upper arm.
- C. Abdomen.
- D. Lower back.
Correct Answer: C
Rationale: the abdomen is a preferred site for insulin injection due to consistent absorption rates
A client with internal radiation.
Which of the following actions, if taken by the nurse, is MOST important?
- A. Restrict visitors who may have an upper respiratory infection.
- B. Assign only male caregivers to the client.
- C. Plan nursing activities to decrease nurse exposure.
- D. Wear a lead-lined apron whenever delivering client care.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) all visitors are restricted with regard to the distance they should be from the client (2) not relevant to the situation (3) correct-principles for radiation therapy are time, distance, shielding; nurse should decrease the time spent in close proximity to the client (4) appropriate shielding (lead aprons) is to be used when the nurse has to spend any length of time at a close distance, not just for routine care
Which of the following nursing observations documented in the client's chart MOST clearly indicates the client's mood?
- A. Client states, 'I see snakes climbing on the walls at all times of the day.'
- B. Unable to sustain a train of thought for long periods of time during history-taking.
- C. Clenches her fists and shouts in an angry tone of voice when asked about family problems.
- D. Is unaware of where she is, what day and year it is, or what time it is.
Correct Answer: C
Rationale: gives data that reflect client's feelings, tone, and behavior associated with those feelings, as well as content area of conversation that evoked that mood
A client is scheduled for a cholangiogram. Meglumine diatrizoate (Gastrografin) is ordered for the client.
The nurse should
- A. identify the client before administering the medication.
- B. administer the medication two hours before the procedure.
- C. administer an enema after administering the medication.
- D. instruct the client to take medication slowly with water.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-appropriate identification of client is the first nursing priority after the order is verified (five 'rights' of medication administration) (2) unnecessary (3) unnecessary (4) unnecessary
A three-month-old is placed in Bryant's traction for developmental dysplasia of the hips. Which of the following toys would be appropriate for the nurse to offer the infant during hospitalization?
- A. A rattle.
- B. A stuffed animal.
- C. Colorful blocks.
- D. A tape playing nursery rhymes.
Correct Answer: A
Rationale: three-month-old can grasp a rattle