Nokea
A client with cancer is to undergo an intravenous pyelogram. The nurse should:
- A. Ensure adequate fluid intake 24 hours before the procedure
- B. Ask the client to void immediately before the study
- C. Administer medication that affects the central nervous system as prescribed
- D. Position the client appropriately for the procedure
Correct Answer: B
Rationale: The correct answer is to ask the client to void immediately before the study. For an intravenous pyelogram, the client may have orders for laxatives or enemas, so ensuring the client voids before the test is important to prevent obscuring visualization of the kidney, ureters, and bladder. Choice A is incorrect because there is no need to force fluids before the procedure. Choice C is incorrect as medications affecting the central nervous system should not be held unless specified by the healthcare provider. Choice D is incorrect as covering the reproductive organs with an x-ray shield is not necessary for an intravenous pyelogram.
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A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:
- A. Trendelenburg position
- B. Ice to the entire extremity
- C. Buck's traction
- D. An abduction pillow
Correct Answer: C
Rationale: The correct answer is Buck's traction. This intervention is used to realign the fractured femur, reduce spasms, and alleviate pain. Placing the client in the Trendelenburg position is inappropriate for a femur fracture, making answer A incorrect. While ice may be used post-repair, applying it to the entire extremity is unnecessary, so answer B is wrong. An abduction pillow is typically employed following a total hip replacement, not for a fractured femur, rendering answer D incorrect.
Which task should not be performed by the licensed practical nurse?
- A. Inserting a Foley catheter
- B. Discontinuing a nasogastric tube
- C. Obtaining a sputum specimen
- D. Initiating a blood transfusion
Correct Answer: D
Rationale: A licensed practical nurse should not initiate a blood transfusion. LPNs can assist with transfusions and verify ID numbers but should not be assigned to initiate the procedure. Inserting Foley catheters, discontinuing nasogastric tubes, and obtaining sputum specimens are within the scope of practice for LPNs. Therefore, options A, B, and C are tasks that LPNs can perform, making them incorrect choices.
The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:
- A. Rotating application sites
- B. Limiting applications to the chest
- C. Rubbing it into the skin
- D. Covering it with a thin paper dressing
Correct Answer: A
Rationale: Proper application of nitroglycerin ointment involves rotating application sites to prevent skin irritation. It should be applied to the back and upper arms, not restricted to the chest, making option B incorrect. Rubbing it into the skin, as indicated in option C, is not recommended for nitroglycerin ointment as it can lead to faster absorption and potential side effects. The correct way is to cover it with a thin paper dressing, not gauze as mentioned in option D, to ensure proper absorption and prevent the medication from evaporating too quickly.
The nursing assistant hitting the client in the long-term care facility can be charged with:
- A. Negligence
- B. Tort
- C. Assault
- D. Malpractice
Correct Answer: C
Rationale: Assault is the appropriate charge in this scenario. Assault involves physically striking or touching someone inappropriately. Negligence (Choice A) refers to failing to provide proper care for the client. Tort (Choice B) is a wrongful act committed against the client or their property. Malpractice (Choice D) is the failure to perform an act that should have been done or the improper performance of an act resulting in harm to the client. Since the nursing assistant physically struck the client, the charge of assault is most fitting.
A client sitting alone and talking to voices is observed by a nurse. When asked, the client reports he is 'talking to the voices.' The nurse's next action should be:
- A. touching the client to help him return to reality
- B. leaving the client alone until reality returns
- C. asking the client to describe what is happening
- D. telling the client there are no voices
Correct Answer: C
Rationale: When a client reports talking to voices, it can indicate the presence of hallucinations. Asking the client to describe what is happening is a crucial step as it helps the nurse understand the nature of the hallucinations and provides reassurance to the client. Touching the client without consent is inappropriate and can be distressing. Leaving the client alone may not address the underlying issue, and telling the client there are no voices denies their experience and can lead to mistrust.