Nokea
A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should tell the client that:
- A. The test may be painful
- B. The test takes 2 to 3 hours
- C. Food and fluids are not allowed for 4 hours after the test
- D. Dye is injected and may cause a warm flushing sensation
Correct Answer: D
Rationale: The correct answer is D. A contrast-aided CT scan involves the injection of dye to enhance the images obtained. The dye may cause a warm flushing sensation when injected, which is a common side effect. Choices A, B, and C are incorrect. CT with contrast is generally not a painful procedure, the duration of the test does not usually take 2 to 3 hours, and restrictions on food and fluids are typically before the test, not afterward.
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What should the nurse do before an echocardiogram for a client who has had a myocardial infarction?
- A. Ensuring no food or drink for 4 hours before the procedure
- B. Obtaining informed consent from the client
- C. Assessing for any history of iodine or shellfish allergies
- D. Informing the client about the painless nature and duration of the procedure
Correct Answer: D
Rationale: The correct answer is to inform the client that the echocardiogram is a painless procedure that usually takes 30 to 60 minutes to complete. Echocardiography is a noninvasive, risk-free, and pain-free test that uses ultrasound to evaluate the heart's structure and motion. There is no need for special preparation before the procedure. Choices A, B, and C are incorrect because imposing nothing-by-mouth status, obtaining informed consent, and assessing for allergies to iodine or shellfish are not necessary steps before an echocardiogram.
An emergency department nurse assesses a client with kidney trauma and notes that the client's abdomen is tender and distended, and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation?
- A. Assessing vital signs every 15 minutes
- B. Inserting an indwelling urinary catheter
- C. Administering intravenous fluids at 125 mL/hr
- D. Typing and crossmatching for blood products
Correct Answer: B
Rationale: In a client with kidney trauma and blood visible at the urinary meatus, inserting a urinary catheter via the urethra should be avoided until further diagnostic studies are completed to prevent potential urethral tears. The nurse should consult the provider about the need for a catheter; if necessary, a suprapubic catheter can be used instead. Assessing vital signs every 15 minutes is important for continuous monitoring of the client's condition. Administering intravenous fluids at 125 mL/hr is crucial to maintain hydration and support kidney function. Typing and crossmatching for blood products is necessary in case the client requires blood transfusion due to potential blood loss from the trauma.
A client in the emergency department is severely dehydrated and is prescribed 3 L of intravenous fluid over 6 hours. At what rate (mL/hr) should the nurse set the intravenous pump to infuse the fluids? (Record your answer using a whole number.)
- A. 500 mL/hr
- B. 400 mL/hr
- C. 550 mL/hr
- D. 600 mL/hr
Correct Answer: A
Rationale: To calculate the rate of the intravenous pump, divide the total volume of fluid (3 L = 3000 mL) by the total time in hours (6 hours), which equals 500 mL/hr. The correct answer is A. Choice B (400 mL/hr) is incorrect as it would result in a slower infusion rate. Choice C (550 mL/hr) and Choice D (600 mL/hr) are incorrect as they would result in a faster infusion rate, exceeding the prescribed amount of fluid to be infused over 6 hours.
A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which of the following signs and symptoms does the nurse assess this client?
- A. Disorientation and dyspnea
- B. Drowsiness, headache, and tachypnea
- C. Tachypnea, dizziness, and paresthesias
- D. Dysrhythmias and decreased respiratory rate and depth
Correct Answer: D
Rationale: The correct answer is D. A client with metabolic alkalosis may present with dysrhythmias and a decreased respiratory rate and depth as the body tries to compensate by retaining carbon dioxide. Options A, B, and C do not typically correlate with the signs and symptoms of metabolic alkalosis. Disorientation, dyspnea, drowsiness, headache, tachypnea, dizziness, and paresthesias are not commonly associated with metabolic alkalosis. Therefore, they are incorrect choices.
A nurse plans care for an older adult client. Which interventions should the nurse include in this client's plan of care to promote kidney health? (Select all that apply.)
- A. Ensure adequate fluid intake.
- B. Leave the bathroom light on at night.
- C. Encourage use of the toilet every 6 hours.
- D. A & B
Correct Answer: D
Rationale: The correct interventions to promote kidney health in an older adult client include ensuring adequate fluid intake to maintain hydration and leaving the bathroom light on at night to promote safe ambulation. Adequate hydration supports kidney function and helps prevent urinary tract infections. Encouraging the use of the toilet every 6 hours is not specific to kidney health and may not be individualized to the client's needs. Providing thorough perineal care after each voiding is important for hygiene but not directly related to promoting kidney health. Assessing for urinary retention and urinary tract infections is crucial but falls under assessment rather than interventions for promoting kidney health specifically.