Nokea
A magnetic resonance imaging (MRI) scan is prescribed for a client with a suspected brain tumor. Which prescription should the nurse anticipate will be prescribed for the client before the procedure?
- A. An opioid
- B. A sedative
- C. A corticosteroid
- D. An antihistamine
Correct Answer: B
Rationale: An MRI scan is a noninvasive diagnostic test that visualizes the body's tissues, structure, and blood flow. For an MRI, the client is positioned on a padded table and moved into a cylinder-shaped scanner. Relaxation techniques, an eye mask, and sedation are used before the procedure to reduce claustrophobic effects; however, because the client must remain very still during the scan, the nurse avoids oversedating the client to ensure client cooperation. There is no useful purpose for administering an opioid, corticosteroid, or antihistamine.
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The clinic nurse prepares to assess a client who is in the second trimester of pregnancy. When measuring the fundal height, what should the nurse expect to note with this measurement regarding gestational age?
- A. It is less than gestational age.
- B. It correlates with gestational age.
- C. It is greater than gestational age.
- D. It has no correlation with gestational age.
Correct Answer: B
Rationale: Until the third trimester, the measurement of fundal height will, on average, correlate with the gestational age. Therefore, options 1, 3, and 4 are incorrect.
The nurse assesses a peripheral intravenous (IV) dressing and notes that it is damp and the tape is loose. What action should the nurse take initially?
- A. Stop the infusion immediately.
- B. Apply a sterile, occlusive dressing.
- C. Ensure all IV tubing connections are tight.
- D. Gather the supplies needed to insert a new IV.
Correct Answer: C
Rationale: To determine subsequent nursing interventions, the nurse checks all connections to ensure tight seals while the IV infuses to help locate the source of the leak. If the leak is at the insertion site, the nurse stops the infusion, removes the IV, and inserts a new IV catheter. The nurse applies a new sterile occlusive dressing after resolving the source of the leak.
The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How should the nurse correctly analyze these results?
- A. The results are positive for active tuberculosis.
- B. The results indicate a less virulent strain of tuberculosis.
- C. The results are inconclusive until a repeat sputum specimen is sent.
- D. The results are unreliable unless the client has also had a positive tuberculin skin test (TST).
Correct Answer: A
Rationale: Culture of Mycobacterium tuberculosis from sputum or other body secretions or tissue confirms the diagnosis of active tuberculosis.
A client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which intervention should the nurse implement before administering the antibiotic?
- A. Turn off the TPN for 30 minutes.
- B. Ensure a separate IV access route.
- C. Flush the CVC with normal saline.
- D. Check for compatibility with TPN.
Correct Answer: B
Rationale: The TPN line is used only for the administration of the TPN solution to prevent crystallization in the CVC tubing and disruption of the TPN infusion. Any other IV medication must be administered through a separate IV access site, including a separate infusion port of the CVC catheter. Therefore, options 1, 3, and 4 are incorrect actions.
A child diagnosed with rheumatic fever is admitted to the hospital. The nurse prepares to manage which clinical manifestations of this disorder? Select all that apply.
- A. Cardiac murmur
- B. Cardiac enlargement
- C. Cool pale skin over the joints
- D. White painful skin lesions on the trunk
- E. Small nontender lumps on bony prominences
- F. Purposeless jerky movements of the extremities and face
Correct Answer: A,B,E,F
Rationale: Rheumatic fever is a systemic inflammatory disease that may develop as a delayed reaction to an inadequately treated infection of the upper respiratory tract by group A beta-hemolytic streptococci. Clinical manifestations of rheumatic fever are related to the inflammatory response. Major manifestations include carditis manifested as inflammation of the endocardium, including the valves, myocardium, and pericardium; cardiac murmur and cardiac enlargement; subcutaneous nodules, manifested as small nontender lumps on joints and bony prominences; chorea, manifested as involuntary, purposeless jerky movements of the legs, arms, and face with speech impairment; arthritis manifested as tender, warm erythematous skin over the joints; and erythema marginatum, manifested as red, painless skin lesions usually over the trunk.