Nokea
A nurse is caring for a client who is scheduled for a colonoscopy. Which of the following findings should the nurse report to the provider?
- A. Client reports taking ibuprofen daily
- B. Client has a history of asthma
- C. Client reports drinking one glass of wine daily
- D. Client has a history of diverticulitis
Correct Answer: A
Rationale: The correct answer is A. Ibuprofen is an NSAID that can increase the risk of bleeding during a colonoscopy due to its effects on platelet function. It is important to report this finding to the provider to consider alternative pain management options. Choices B, C, and D are not the most pertinent to report for a colonoscopy. Asthma and a history of diverticulitis are relevant medical history but do not directly impact the colonoscopy procedure. Drinking one glass of wine daily is not a concern specifically related to the colonoscopy procedure.
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A client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?
- A. Encourage the client to increase dietary fiber.
- B. Maintain the client on a low-residue diet.
- C. Provide the client with frequent high-calorie snacks.
- D. Encourage the client to eat a high-fiber diet.
Correct Answer: B
Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.
A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?
- A. Obtain the newborn's body temperature using a tympanic thermometer
- B. Pull the pinna of the infant's ear forward before inserting the probe
- C. Auscultate the newborn's apical pulse for 60 seconds
- D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence
Correct Answer: C
Rationale: The correct answer is C: Auscultate the newborn's apical pulse for 60 seconds. When assessing a newborn, it is essential to auscultate the apical pulse for a full 60 seconds to accurately determine their heart rate. This method allows for a more precise measurement, considering the variability in heart rates in newborns. Choice A is incorrect because tympanic thermometers are not typically used for newborns due to their ear canals being small and not fully developed. Choice B is incorrect as pulling the pinna forward is not necessary for assessing the apical pulse. Choice D is incorrect as measuring head circumference involves a different assessment and is not relevant to determining the heart rate of a newborn.
While caring for a client receiving hemodialysis, which action should the nurse include in the plan of care?
- A. Withhold all medications until after dialysis.
- B. Check the vascular access site for bleeding after dialysis.
- C. Rehydrate with dextrose 5% in water for hypotension.
- D. Give an antibiotic 30 minutes before dialysis.
Correct Answer: B
Rationale: The correct action the nurse should include in the plan of care when caring for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial to monitor for any signs of bleeding or complications at the access site. Withholding all medications until after dialysis (Choice A) is not necessary unless specified for certain medications. Rehydrating with dextrose 5% in water for hypotension (Choice C) is not appropriate for addressing hypotension related to hemodialysis. Giving an antibiotic 30 minutes before dialysis (Choice D) is not typically indicated unless there is a specific medical indication for prophylactic antibiotic use.
A client who is at 36 weeks of gestation is scheduled for a nonstress test (NST). Which of the following statements by the client indicates an understanding of the teaching?
- A. I should fast for 12 hours before the test.
- B. I should expect the test to take about 10 minutes.
- C. I should have a full bladder for this test.
- D. I will need to have my blood glucose checked before the test.
Correct Answer: B
Rationale: The correct answer is B. The nonstress test typically takes about 10 minutes and evaluates the fetal heart rate in response to fetal movement. Having a full bladder or fasting for 12 hours is not required for a nonstress test. Checking blood glucose levels is not part of the nonstress test procedure.
A nurse is preparing to administer a dose of digoxin to a client who has heart failure. Which of the following actions should the nurse take prior to administering the medication?
- A. Monitor the client's respiratory rate.
- B. Assess the client's apical pulse.
- C. Review the client's potassium level.
- D. Monitor the client's fluid intake.
Correct Answer: B
Rationale: The correct action the nurse should take prior to administering digoxin is to assess the client's apical pulse. Digoxin is known to affect the heart rate, potentially causing bradycardia. Monitoring the client's respiratory rate (Choice A) is not directly related to administering digoxin. Reviewing the client's potassium level (Choice C) is important but not a direct prerequisite for administering digoxin. Monitoring the client's fluid intake (Choice D) is also important but not a specific action to take just before administering digoxin.