Nokea
A client is scheduled for a cardiac catheterization. The nurse should do which of the following preprocedure tasks? Select all that apply.
- A. Administer all ordered oral medications.
- B. Check for iodine sensitivity.
- C. Verify that written consent has been obtained.
- D. Withhold food and oral fluids before the procedure.
- E. Insert a urinary drainage catheter.
Correct Answer: B,C,D
Rationale: Checking iodine sensitivity (B), verifying consent (C), and withholding food/fluids (D) are standard pre-catheterization tasks to ensure safety and preparedness.
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Following a laryngectomy, the nurse notices that the client has saliva collecting beneath the skin flaps. This finding is indicative of which of the following?
- A. Skin necrosis.
- B. Carotid artery rupture.
- C. Stomal Stenosis.
- D. Development of a fistula.
Correct Answer: D
Rationale: Saliva collecting beneath skin flaps post-laryngectomy indicates a fistula, where saliva leaks from the pharynx or esophagus into surrounding tissues, requiring immediate attention.
Lifestyle influences that are considered risk factors for colorectal cancer include:
- A. A diet low in vitamin C.
- B. A high dietary intake of artificial sweeteners (Aspartame).
- C. A high-fat, low-fiber diet.
- D. Multiple sex partners.
Correct Answer: C
Rationale: A high-fat, low-fiber diet is a well-established risk factor for colorectal cancer, as it slows digestion and increases exposure to potential carcinogens in the colon.
The nurse prepares to administer promethazine (Phenergan) 35 mg I.M. as ordered p.r.n. for a client with cholecystitis complaining of nausea. The ampule label reads that the medication is available in 25 mg/mL. How many milliliters should the nurse administer?
Correct Answer: 1.4 mL
Rationale: To calculate: 35 mg ÷ 25 mg/mL = 1.4 mL. Thus, the nurse should administer 1.4 mL of promethazine.
What is the nurse's best action for a client with a suspected stroke and aphasia?
- A. Speak loudly.
- B. Use simple phrases.
- C. Write all instructions.
- D. Avoid communication.
Correct Answer: B
Rationale: Using simple phrases supports communication in stroke patients with aphasia.
A client with malignant pleural effusions is complaining of dyspnea and chest pain. Place the following interventions that the nurse should perform in the correct order of priority.
- A. Administer morphine sulfate 2 mg I.V.
- B. Apply oxygen at 2 L via nasal cannula.
- C. Educate the client in anticipation of a thoracentesis.
- D. Coach the client on deep breathing exercise.
Correct Answer: B,A,C,D
Rationale: Oxygen (B) addresses immediate hypoxia, morphine (A) relieves pain and dyspnea, education for thoracentesis (C) prepares for definitive treatment, and deep breathing (D) supports respiratory function.