Nokea
A client is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?
- A. Monitor the client for pain in the suprapubic region.
- B. Ensure the client is free of metal objects.
- C. Administer 240 mL (8 oz) of oral contrast before the procedure.
- D. Assist the client with a bowel cleansing.
Correct Answer: B
Rationale: The correct action for the nurse to include before an intravenous pyelogram is ensuring the client is free of metal objects. Metal objects can interfere with the imaging procedure and may need to be removed to prevent artifacts. Monitoring for pain in the suprapubic region (choice A) is not directly related to the procedure and is not a standard pre-procedure action. Administering oral contrast (choice C) is more common for other imaging studies like a CT scan, not an intravenous pyelogram. Assisting with a bowel cleansing (choice D) is not typically required before an intravenous pyelogram.
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A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?
- A. Firmly tell the client not to grab
- B. Redirect the client's attention
- C. Use physical restraints
- D. Avoid contact with the client
Correct Answer: B
Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.
The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?
- A. Spaghetti
- B. Watermelon
- C. Chicken
- D. Tomatoes
Correct Answer: B
Rationale: The correct answer is 'Watermelon.' Watermelon is high in potassium, which is important to counteract the potassium loss caused by furosemide. Furosemide is a loop diuretic that can lead to potassium depletion, so consuming potassium-rich foods like watermelon can help maintain electrolyte balance. Choices A, C, and D do not specifically address the need for potassium in this scenario and are not as beneficial for addressing the potential electrolyte imbalance caused by furosemide.
A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?
- A. Collapsing the device whenever it is 1/2 to 2/3 full of air.
- B. Emptying the device every 4 hours.
- C. Replacing the device every 24 hours.
- D. Keeping the device above the level of the surgical site.
Correct Answer: A
Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.
During an assessment, a client receiving tube feedings via NG tube shows signs of nasal mucosa irritation. What finding should the nurse report to the provider?
- A. Potassium 5.5 mEq/L
- B. Irritation of nasal mucosa
- C. Sodium 144 mEq/L
- D. Loose stools
Correct Answer: B
Rationale: Irritation of nasal mucosa is a crucial finding that the nurse should report to the provider as it suggests potential complications with NG tube placement, such as improper positioning or mucosal damage. High potassium levels (Choice A) can be concerning but are not directly related to NG tube placement issues. Normal sodium levels (Choice C) and loose stools (Choice D) are common occurrences in clients receiving tube feedings and are not typically indicative of immediate complications that require urgent reporting.
A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?
- A. Patient is lying on side.
- B. Patient is lying on back.
- C. Patient is lying semiprone.
- D. Patient is lying on abdomen.
Correct Answer: A
Rationale: The correct answer is A: 'Patient is lying on side.' In the side-lying (or lateral) position, the patient rests on the side with the major portion of body weight on the dependent hip and shoulder. Choice B, 'Patient is lying on back,' is incorrect as it describes a supine position. Choice C, 'Patient is lying semiprone,' is incorrect as it refers to a position where the patient is partially lying on the abdomen. Choice D, 'Patient is lying on abdomen,' is incorrect as it describes a prone position where the patient is lying face down.