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. A client with a suspected left sided heart failure is scheduled to undergo a multigated acquisition scan. Which of the following actions is required before undergoing the test?
- A. Diuretics are administered
- B. Client should avoid fluid intake 6 hours
- C. Client is medicated to relieve cough before the test
- D. Client is administered analgesics
Correct Answer: C
Rationale: Rationale:
- A: Diuretics are not necessary before the test and may affect test results.
- B: Dehydration is not recommended before the test as it can impact cardiac function.
- C: Medication to relieve cough is necessary to reduce any potential interference with the scan.
- D: Administering analgesics is not required for the test and may not be relevant to the client's condition.
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Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:
- A. For its synergestic effect
- B. Because of the client's resistance to
- C. To rule out cholinergic crisis Neostigmine
- D. To confirm the diagnosis of myasthenia
Correct Answer: C
Rationale: The correct answer is C: To rule out cholinergic crisis caused by Neostigmine. Edrophonium HCL is a fast-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis. If the patient's weakness improves after administration of edrophonium, it indicates that the weakness was due to myasthenia gravis and not cholinergic crisis caused by excessive neostigmine. Choice A is incorrect because there is no synergestic effect between neostigmine and edrophonium. Choice B is incorrect as resistance to neostigmine is not a valid reason for ordering edrophonium. Choice D is incorrect because edrophonium is used for differential diagnosis, not for confirming the diagnosis of myasthenia gravis.
Mr Santos is scheduled for CT SCAN for the next day, noon time. Which of the following is the correct preparation as instructed by the nurse?
- A. Shampoo hair thoroughly to remove oil and dirt
- B. No special preparation is needed. Instruct the patient to keep his head still and stead
- C. Give a cleansing enema and give fluids until 8 AM
- D. Shave scalp and securely attach electrodes to it
Correct Answer: A
Rationale: The correct answer is A because shampooing the hair thoroughly helps remove oil and dirt, which can interfere with the CT scan results. By having clean hair, the scan can produce clearer images.
Choice B is incorrect because some preparation is needed for a CT scan, especially regarding cleanliness.
Choice C is incorrect as giving a cleansing enema and fluids until 8 AM is not necessary for a CT scan of the head.
Choice D is incorrect as shaving the scalp and attaching electrodes are not part of routine preparation for a CT scan.
Nurse Karen is caring for a client with chronic renal failure. Which is a correct intervention for hyperkalemia?
- A. assess patient for fever and chest pain
- B. assess patient for muscle weakness, diarrhea and ECG changes
- C. encourage compliance with fluid restriction
- D. prepare patient for cardiac ultrasound
Correct Answer: B
Rationale: The correct answer is B because hyperkalemia presents with symptoms such as muscle weakness, diarrhea, and ECG changes. Muscle weakness is a common sign due to potassium's effect on neuromuscular function. Diarrhea can lead to potassium loss. ECG changes, such as peaked T waves and widened QRS complexes, indicate cardiac involvement. Assessing for these symptoms helps monitor the severity of hyperkalemia and guide treatment. Other choices are incorrect because assessing for fever and chest pain (choice A) are not specific to hyperkalemia. Encouraging fluid restriction (choice C) may not directly address hyperkalemia. Preparing for a cardiac ultrasound (choice D) is not an immediate intervention for hyperkalemia.
An adult is to receive narcotic analgesics via patient controlled analgesia. The nurse is evaluating client’s understanding of the procedure. Which of the following statements by the client indicates that she understand PCA?
- A. When I press this button the machine will always give me more medicine.
- B. I will press the button whenever I feel pain
- C. I should press this button every hour so the pain doesn’t come back
- D. With this machine I will experience no more pain
Correct Answer: B
Rationale: The correct answer is B: "I will press the button whenever I feel pain." This answer demonstrates understanding of how patient-controlled analgesia (PCA) works, where the client self-administers medication when needed for pain relief. Option A is incorrect as the machine is programmed with lockout intervals to prevent overdosing. Option C is incorrect as the client should only press the button when experiencing pain, not on a fixed schedule. Option D is incorrect as PCA does not guarantee complete pain elimination. The key in PCA is empowering the client to self-administer medication based on their pain level.
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it is essential to assess the severity of the latex allergy to determine the appropriate precautions and interventions. By asking the patient to describe the type of reaction, the nurse can gather crucial information to ensure patient safety.
Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview prematurely is not appropriate without gathering important information about the allergy. Choice D is incorrect because documenting the allergy is important, but assessing the type of reaction should be the initial priority.