Nokea
A nurse is observing a client during an excretory urogram. Which of these observations indicate a complication is occurring?
- A. The client complains of a salty taste in the mouth when the dye is injected.'
- B. The client's entire body turns a bright red color.'
- C. The client states 'I have a feeling of getting warm.''
- D. The client gags and complains 'I am getting sick.''
Correct Answer: B
Rationale: The client's entire body turns a bright red color.' This observation suggests anaphylaxis which results in massive vasodilation. Other findings would be immediate wheezing and/or respiratory arrest.
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A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce?
- A. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum)
- B. It is critical to report promptly to your health care provider any findings of peptic ulcers
- C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors
- D. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine
Correct Answer: B
Rationale: It is critical to report promptly to your health care provider any findings of peptic ulcers. Such findings include night-time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite.
The nurse is completing a variance report after finding a plastic bag at the nurse's station with contents and the sticker illustrated. The nurse should document finding a plastic bag with a symbol indicating that the contents of the bag include which type of item?
- A. Potentially infectious specimen
- B. Radioactive medication
- C. Flammable substance
- D. Poisonous substance
Correct Answer: A
Rationale: A: The biohazard symbol indicates potentially infectious material. B, C, D: Other symbols (trefoil, NFPA diamond) denote radiation, flammability, or toxicity.
When caring for a client with a post-right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote
- A. relaxation and sleep
- B. deep breathing and coughing
- C. incisional healing
- D. range of motion exercises
Correct Answer: B
Rationale: The priority is preventing postoperative respiratory complications. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. Client compliance with recommended deep breathing and coughing exercises will only be achieved with the appropriate pain management.
The infection control nurse receives hospital laboratory confirmation that the client has positive sputum cultures for mycobacterium tuberculosis. Which action should be taken by the nurse?
- A. Prepare a statement for the hospital spokesperson to release to the news agencies
- B. Recommend that only staff with recent negative tuberculin skin tests provide care
- C. Implement measures to notify the local or state health department about the case
- D. Notify the nearest infectious disease facility and prepare the client for transfer
Correct Answer: C
Rationale: C: TB is a reportable disease, requiring health department notification. A: Media release is inappropriate. B: All staff can provide care with precautions. D: Transfer is unnecessary.
The nurse observes that the NA enters the client room, provides direct care, and then exits without performing any hand hygiene. Which is the appropriate initial action of the nurse?
- A. Inform the nurse manager about the NA's performance.
- B. File a facility incident or variance report immediately.
- C. Talk to the NA immediately about performing hand hygiene.
- D. Tell the client to remind all staff to perform hand hygiene.
Correct Answer: C
Rationale: C: Immediate discussion with the NA addresses the issue directly and promotes compliance. A, B: These are secondary actions. D: Client involvement is inappropriate.