A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)
- A. Ask the client about any allergies
- B. Evaluate the client's renal function
- C. Ensure informed consent is present
- D. Assess breath sounds
- E. Assess hematocrit and hemoglobin levels
Correct Answer: A,B,C
Rationale: Asking about allergies (especially to iodine or shellfish), evaluating renal function, and ensuring informed consent are critical to safely administer iodine-based contrast. Assessing breath sounds or hematocrit/hemoglobin is unrelated to CT preparation.
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A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication should prompt the nurse to contact the health care provider?
- A. Weak pedal pulses
- B. Nausea and vomiting
- C. Increased thirst
- D. Hives on the chest
Correct Answer: B
Rationale: Nausea, vomiting, severe headache, photophobia, or altered consciousness post-LP indicate increased intracranial pressure, requiring immediate provider notification. The other findings are not specific to LP complications.
A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client?
- A. You may return to your previous activity level immediately.
- B. You are radioactive and must use a private bathroom.
- C. Frequent assessments of the injection site will be completed.
- D. We will be monitoring your renal function closely.
Correct Answer: A
Rationale: No special precautions are needed after SPECT, as radioisotopes are eliminated in urine without requiring monitoring or activity restrictions. The other options are unnecessary.
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement?
- A. Educate the client about strict bedrest after the procedure.
- B. Obtain a prescription for intravenous fluids.
- C. Assess the client's gag reflex.
- D. Insert an indwelling urinary catheter.
Correct Answer: B
Rationale: Intravenous fluids promote excretion of contrast medium, protecting the kidneys in clients with renal insufficiency. Bedrest is not required, gag reflex is unaffected, and an indwelling catheter is unnecessary unless otherwise indicated.
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure?
- A. Creatine phosphokinase (CPK) of 100 IU/L.
- B. Atrioventricular graft.
- C. Blood urea nitrogen (BUN) of 50 mg/dL.
- D. Internal insulin pump.
Correct Answer: D
Rationale: Metal devices like an internal insulin pump can interfere with MRI imaging and be displaced by magnetic forces, necessitating cancellation. CPK, BUN levels, and atrioventricular grafts do not contraindicate MRI.
A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care?
- A. Check bath water temperature with a thermometer.
- B. Provide the client with assistance when ambulating.
- C. Place elastic support hose on the client's legs.
- D. Allow the client to use a white board to ask questions.
Correct Answer: B
Rationale: Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. Providing ambulation assistance helps prevent injury by ensuring the client has support while walking. The other interventions do not address the balance and coordination issues caused by hypoactive reflexes.
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