Nokea
A client asks, 'What should I do to prepare for a colonoscopy?' Which instructions should the nurse reinforce to correctly answer the client’s question? Select all that apply.
- A. No food or drink is allowed 8 hours prior to the test
- B. Prophylactic antibiotics are taken as prescribed
- C. Smoking must be avoided after midnight
- D. The day prior to the procedure your diet will be clear liquids
- E. You will drink polyethylene glycol as directed the day before
Correct Answer: A,D,E
Rationale: Fasting 8 hours, clear liquids the day before, and polyethylene glycol are standard colonoscopy preparations. Antibiotics are not routine, and smoking cessation is not specific to the procedure.
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The father of an 8 month-old infant asks the nurse if his child's vocalizations are normal for his age. Which of the following would the nurse expect at this age?
- A. Cooing
- B. Imitation of sounds
- C. Throaty sounds
- D. Laughter
Correct Answer: B
Rationale: Imitation of sounds. Eight-month-olds typically imitate sounds like 'da-da' as part of language development.
The nurse is caring for a postoperative client who is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client can be roused and responds to verbal commands. One hour later, the client is again difficult to rouse, with minimal response to physical stimuli. Which actions does the nurse anticipate? Select all that apply.
- A. Administration of oxygen
- B. Administration of a 2nd dose of naloxone
- C. Discontinuation of pain medication
- D. Initiation of a rapid response or code team
- E. Monitoring of respiratory rate
Correct Answer: A,B,E
Rationale: Recurrent unresponsiveness suggests opioid re-narcotization, requiring oxygen, a second naloxone dose, and respiratory monitoring. Discontinuing pain medication is premature, and rapid response is not yet indicated.
The nurse is preparing a client for cervical uterine radiation implant insertion. Which will the nurse expect to be included in the teaching plan?
- A. TV or telephone use will not be allowed while the implant is in place.
- B. A Foley catheter is usually inserted.
- C. A high fiber diet is recommended.
- D. Excretions will be considered radioactive.
Correct Answer: B
Rationale: A catheter allows urine elimination without possible disruption of the implant. There is usually no restriction on TV or phone use, so answer A is incorrect. The client is placed on a low residue diet, so answer C is incorrect. The client's radiation is not internal; therefore, there are no special precautions with excretions, making answer D incorrect.
A client who has Mycoplasma pneumonia needs to go to the radiology department for a chest x-ray. What should the client wear?
- A. A face shield
- B. A surgical mask
- C. An N95 respirator
- D. Gloves and a gown
Correct Answer: B
Rationale: A surgical mask prevents droplet transmission of Mycoplasma pneumonia during transport, protecting others.
The nurse is assessing a client who had a thyroidectomy 12 hours ago and is reporting anxiety, tingling around the mouth, and muscle twitching in the hand. Which of the following actions would be a priority for the nurse to take?
- A. Check the area around the incision site for edema
- B. Review the client’s most recent arterial blood gas results
- C. Evaluate the client’s vocal quality and strength
- D. Obtain a blood specimen to check the serum calcium level
Correct Answer: D
Rationale: Anxiety, tingling, and twitching suggest hypocalcemia from parathyroid damage during thyroidectomy, requiring urgent calcium level assessment. Edema, blood gases, and vocal quality are less urgent.