Nokea
A client with suspected foot osteomyelitis is scheduled for an MRI. Which client findings should the nurse report before the test? Select all that apply.
- A. Cardiac pacemaker
- B. Colostomy
- C. Retained metal foreign body in eye
- D. Total hip replacement
- E. Transdermal testosterone patch
Correct Answer: A,C,D
Rationale: Pacemakers, metal in the eye, and hip replacements pose MRI risks due to magnetic interference or heating. Colostomies and transdermal patches are not contraindicated for MRI.
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A client who is blind is admitted to the hospital for surgery tomorrow. The client is able to get out of bed and eat until midnight. Which nursing action is most appropriate?
- A. Describe the surroundings and the objects in the room to the client.
- B. Put up the side rails and have the client ask for help when getting out of bed for any reason.
- C. Describe the voices of the personnel to the client.
- D. Remove objects such as water pitchers and glasses from the immediate vicinity.
Correct Answer: A
Rationale: Describing surroundings aids orientation and safety for a blind client, promoting independence. Side rails, voice descriptions, or removing objects are less helpful.
The nurse is talking with a group of clients at a community health fair about colorectal cancer. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Clients over the age of 50 are at highest risk for colorectal cancer regardless of health status
- B. Consuming low amounts of red meat may reduce the risk for developing colorectal cancer
- C. Clients with inflammatory bowel disease are at higher risk for developing colorectal cancer
- D. Eating plenty of fruits and vegetables and maintaining a healthy weight may reduce the risk for developing colorectal cancer
- E. Clients with a parent or sibling who has had colorectal cancer should have screenings earlier and more often than other clients
Correct Answer: B,C,D,E
Rationale: Low red meat, high fruit/vegetable intake, and healthy weight reduce colorectal cancer risk. Inflammatory bowel disease and family history increase risk, necessitating earlier screenings. Risk rises after age 50, but health status matters, making the first statement inaccurate.
Which nursing action is essential in the care of an adult following a left side cardiac catheterization?
- A. Keep the client NPO for two hours.
- B. Ask the client about a shellfish allergy.
- C. Check pulses proximal to the insertion site.
- D. Check the insertion site for bleeding.
Correct Answer: D
Rationale: Checking the insertion site for bleeding is critical post-catheterization to detect hematoma or hemorrhage, ensuring patient safety.
The nurse is caring for assigned clients. The nurse should first check the client with
- A. sickle cell disease who has new onset pain rated as 9 on a scale of 0-10
- B. pneumonia who has a temperature of 100.6°F (38.1°C) and is receiving IV antibiotics
- C. Graves’ disease who has a heart rate of 110/min and a blood pressure of 122/85 mm Hg
- D. diabetes mellitus who has an elevated serum glucose level and is requesting insulin lispro prior to a meal
Correct Answer: A
Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.
The nurse is caring for a client who was admitted for treatment of schizoaffective disorder with visual hallucinations. He tells the nurse that he sees extraterrestrials that are coming to get him. What is the best nursing response?
- A. You know that extraterrestrials are make-believe.'
- B. Call his physician and report this visual hallucination.
- C. Ignore his comment and change the subject.
- D. You think someone is coming after you?'
Correct Answer: D
Rationale: Reflecting the client's statement validates his experience without reinforcing the hallucination, promoting therapeutic communication.