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A nurse is reinforcing teaching with a client who is scheduled for a colonoscopy. Which of the following statements should the nurse include?
- A. You will be given a sedative during the procedure.
- B. You can eat a light breakfast the morning of the procedure.
- C. You will need to maintain a clear liquid diet for 3 days prior to the procedure.
- D. You will need to take an antibiotic before the procedure.
Correct Answer: A
Rationale: A sedative is used to ensure comfort during a colonoscopy. Clear liquids are required only 1-2 days prior, no food is allowed the morning of, and antibiotics aren't standard.
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A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation?
- A. Place a wedge pillow between the client's legs.
- B. Encourage the client to sit in a recliner.
- C. Allow the client to cross their legs when seated.
- D. Instruct the client to bend at the waist when picking up objects.
Correct Answer: A
Rationale: A wedge pillow maintains abduction, preventing hip dislocation. Recliners, leg crossing, or bending at the waist increase dislocation risk.
A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?
- A. Keep the airbag on if the car seat is in the front seat.
- B. Position the car seat at a 90° angle.
- C. Put a small cushion under the newborn's head for support.
- D. Place the shoulder harnesses at the level of the infant's shoulders.
Correct Answer: D
Rationale: Shoulder harnesses at shoulder level ensure a secure fit, enhancing safety. Airbags should be off for front-seat car seats, the angle should be 45°, and cushions can disrupt proper positioning.
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports pain at the incision site.
- B. The client's temperature is 38.1°C (100.5°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with minimal drainage.
Correct Answer: B
Rationale: A temperature of 38.1°C suggests possible infection, requiring reporting. Pain, no bowel movement, or minimal drainage are expected post-appendectomy.
A nurse is caring for a client who is receiving IV fluids with potassium chloride. Which of the following findings should the nurse report to the provider?
- A. The client reports mild discomfort at the IV site.
- B. The client's heart rate is irregular.
- C. The client's urine output is 50 mL/hr.
- D. The client's blood pressure is 118/76 mm Hg.
Correct Answer: B
Rationale: An irregular heart rate suggests hyperkalemia or arrhythmia, requiring reporting. Mild discomfort, normal urine output, and stable BP are less concerning.
A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?
- A. Verify the dosage with another nurse.
- B. Place the cap over the needle.
- C. Withdraw 10 units of NPH insulin.
- D. Inject 15 units of air into the regular insulin vial.
Correct Answer: D
Rationale: Injecting air into the regular insulin vial follows the sequence for mixing insulins (air into NPH, air into regular, withdraw regular, then NPH), preventing contamination and ensuring accurate dosing.