Nokea
A middle-aged adult is seen in the emergency room for complaints of severe right-flank pain. The client is twenty pounds overweight, lives a sedentary lifestyle, and was treated for renal calculi four years ago. Which of the following actions, if performed by the nurse, is MOST important?
- A. Ensure that the client has nothing to eat or drink.
- B. Obtain a 'clean-catch' urine specimen for analysis.
- C. Provide warm packs to relieve discomfort.
- D. Measure and strain the client's urine.
Correct Answer: D
Rationale: will document passage of stone and allow composition to be analyzed
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While a two-day-old infant is in surgery for repair of spina bifida, the infant's mother expresses concern to the nurse because the doctor told her the infant would be confined to a wheelchair. Which of the following statements, if made by the nurse, is BEST?
- A. Physical therapy can restore the function to affected muscles.
- B. Orthopedic devices will allow your child to strengthen lower extremity muscles.
- C. Corrective surgery will return function to the affected muscles.
- D. The corrective surgery will not change your child's physical disability.
Correct Answer: D
Rationale: spinal nerves that are destroyed by the myelomeningocele cannot be corrected; nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele
A client has received thrombolytic therapy, and the physician has ordered meperidine (Demerol) IM for pain. Before administering the injection, the nurse should
- A. confirm that all lab work has been completed.
- B. verify the order with the physician.
- C. check the client's PTT.
- D. determine that all of the thrombolytic agent has infused.
Correct Answer: B
Rationale: implementation, complications of thrombolytic therapy include bleeding, which can occur with intramuscular injections; nurse should confer with the physician about the appropriateness of the order
While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority?
- A. The medication should be taken once a day for six weeks.
- B. The medication should be taken with orange juice.
- C. The medication should be taken in the morning and at bedtime.
- D. The medication should be taken with meals.
Correct Answer: D
Rationale: will decrease GI upset
A client is scheduled for a cholangiogram. Meglumine diatrizoate (Gastrografin) is ordered for the client.
The nurse should
- A. identify the client before administering the medication.
- B. administer the medication two hours before the procedure.
- C. administer an enema after administering the medication.
- D. instruct the client to take medication slowly with water.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-appropriate identification of client is the first nursing priority after the order is verified (five 'rights' of medication administration) (2) unnecessary (3) unnecessary (4) unnecessary
The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection with an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if performed by the nurse, is BEST?
- A. Change the IV tubing each time a new IV solution is hung.
- B. Cleanse the IV site with an alcohol swab using long strokes.
- C. Limit manipulation of the cannula at the IV insertion site.
- D. Adjust the drop rate to keep the total volume of IV fluids on schedule.
Correct Answer: C
Rationale: will prevent dislodgment of needle