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A client is scheduled for a colonoscopy and has been prescribed a bowel preparation. What is the most important instruction for the nurse to provide?
- A. Eat a low-fiber diet the day before the procedure
- B. Drink clear liquids 24 hours before the procedure
- C. Take the entire bowel preparation as directed
- D. Avoid all solid foods 12 hours before the procedure
Correct Answer: C
Rationale: The most important instruction for the nurse to provide to a client scheduled for a colonoscopy and prescribed a bowel preparation is to take the entire bowel preparation as directed. Completing the entire bowel preparation as prescribed is crucial to ensure the colon is properly cleansed for the colonoscopy. Incomplete bowel prep can interfere with the visualization of the colon, leading to inaccurate results. Choices A, B, and D are important but not as crucial as ensuring the complete intake of the bowel preparation for an effective procedure.
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After placing a stethoscope to auscultate S1 and S2 heart sounds, what should the nurse do to check for an S3 heart sound?
- A. Switch to the diaphragm of the stethoscope to hear any abnormal sounds
- B. Listen with the bell of the stethoscope at the same location
- C. Listen at a different location over the aortic area
- D. Switch to the apical area and reassess for S3 sounds
Correct Answer: B
Rationale: To assess for an S3 heart sound, the nurse should listen with the bell of the stethoscope. An S3 heart sound is often low-pitched and best heard with the bell. Choice A is incorrect because switching to the diaphragm is not ideal for detecting low-pitched sounds like an S3. Choice C is incorrect as the S3 heart sound is best heard over the apex of the heart, not the aortic area. Choice D is incorrect because moving to the apical area is appropriate, but the nurse should specifically use the bell of the stethoscope to listen for S3 sounds.
An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
- A. Administer the medication in 2 separate injections
- B. Give the medication in the dorsal gluteal site
- C. Call to get a smaller volume ordered
- D. Check with the pharmacy for a liquid form of the medication
Correct Answer: A
Rationale: Injections over 1 mL should be split into two separate injections for young children. This helps in preventing discomfort, ensuring proper absorption, and reducing the risk of tissue damage. Giving the medication in one injection of 2.0 ml might be too much for a 2-year-old child. Choices B and D are incorrect because the dorsal gluteal site is not recommended for children due to potential injury, and changing the form of medication might not be necessary if the volume can be adjusted. Choice C is unnecessary as splitting the dose into two injections is the appropriate action.
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse?
- A. A client with a Dopamine drip IV with vital signs monitored every 5 minutes
- B. A client with a myocardial infarction that is free from pain and dysrhythmias
- C. A client with a tracheotomy of 24 hours in some respiratory distress
- D. A client with a pacemaker inserted this morning with intermittent capture
Correct Answer: B
Rationale: In this scenario, it is more appropriate to assign a stable client, such as the one with a myocardial infarction who is free from pain and dysrhythmias, to a nurse who lacks specialized critical care experience. This client's condition is relatively stable and does not require immediate critical interventions. Choices A, C, and D involve clients with more complex and critical conditions that would be better managed by a nurse with specialized critical care training. Choice A involves a client on a Dopamine drip with frequent vital sign monitoring, Choice C has a client with a tracheotomy in respiratory distress, and Choice D describes a client with a pacemaker experiencing intermittent capture, all of which require a higher level of critical care expertise.
A client with a history of atrial fibrillation is prescribed warfarin. What is the nurse's priority teaching?
- A. Avoid eating foods high in potassium.
- B. Avoid foods high in vitamin K.
- C. Take the medication on an empty stomach.
- D. Take the medication at bedtime for best results.
Correct Answer: B
Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Warfarin is an anticoagulant medication that works by interfering with vitamin K-dependent clotting factors. Therefore, consuming foods high in vitamin K can affect the medication's effectiveness. Choices A, C, and D are incorrect because: A) Warfarin is not affected by foods high in potassium; C) Warfarin should be taken with food to minimize gastrointestinal side effects; D) There is no specific requirement for taking warfarin at bedtime for best results.
A client with osteoarthritis is prescribed acetaminophen. What is the most important teaching the nurse should provide?
- A. Take the medication with food to improve absorption.
- B. Avoid taking other pain medications to prevent liver damage.
- C. Take acetaminophen on an empty stomach to prevent stomach upset.
- D. Monitor liver function tests regularly to detect any liver damage.
Correct Answer: B
Rationale: The correct answer is B. Acetaminophen can cause liver damage if taken in excessive amounts or in combination with other medications containing acetaminophen. Clients should be advised to avoid other pain medications to prevent liver toxicity. Choice A is incorrect because acetaminophen is usually taken with or without food, not specifically on an empty stomach. Choice C is incorrect because taking acetaminophen with food can help prevent stomach upset. Choice D is incorrect because while monitoring liver function tests is important for long-term acetaminophen use, the most crucial teaching is to avoid other pain medications to prevent liver damage.