Nokea
A nurse is reinforcing teaching with a client who is scheduled to undergo a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?
- A. I can have clear liquids up to 3 hours before the procedure.
- B. I can eat as soon as the procedure is completed.
- C. I will receive an injection of radioactive material prior to having the procedure.
- D. I might have blood-tinged sputum after the procedure.
Correct Answer: D
Rationale: Blood-tinged sputum is normal post-bronchoscopy due to airway irritation, showing understanding. Clear liquids stop earlier, eating waits until gag reflex returns, and no radiation is involved.
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A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?
- A. Measure the client's intake and output every 8 hr.
- B. Dim the lighting in the client's room.
- C. Monitor the client's temperature every 6 hr.
- D. Initiate contact precautions for the client.
Correct Answer: B
Rationale: Dimming the lighting reduces photophobia, a common symptom of viral meningitis, improving client comfort. Intake/output and temperature monitoring are useful but less specific, and contact precautions are not typically required for viral meningitis.
A nurse is reinforcing teaching with a client who has a prescription for sublingual nitroglycerin for unstable angina. Which of the following instructions should the nurse include in the instructions?
- A. Refill the prescription every 12 months.
- B. Take a second tablet after 5 min for unrelieved chest pain.
- C. Swallow the tablet whole with a glass of water.
- D. Store the medication in the refrigerator.
Correct Answer: B
Rationale: Taking a second dose after 5 minutes for unrelieved pain is standard protocol for nitroglycerin, which is taken sublingually, not swallowed, and stored at room temperature, refilled every 6 months.
A nurse is assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?
- A. Encourage the client to increase oral intake of fluids.
- B. Auscultate the client's abdomen for bowel sounds.
- C. Provide the client privacy with a set time to defecate.
- D. Administer a fiber-based laxative to the client.
- E. Increase physical activity.
- F. Check medication history.
- G. Apply heat to the abdomen.
Correct Answer: B
Rationale: Auscultating bowel sounds assesses the underlying issue (e.g., ileus) before interventions like fluids or laxatives.
A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?
- A. Distended neck veins
- B. Polyuria
- C. Vomiting
- D. Hypertension
- E. Fever and chills
- F. Tachycardia
- G. Hypotension
Correct Answer: C
Rationale: Vomiting is a sign of a septic reaction due to contaminated blood; distended veins suggest fluid overload, polyuria isn't typical, and hypertension isn't specific.
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
- B. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- C. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- D. Platelets 60,000/mm³ (150,000 to 400,000/mm³)
Correct Answer: D
Rationale: Liver biopsy risks bleeding due to vascularity, so platelets at 60,000/mm³ well below normal (150,000-400,000) signal thrombocytopenia, increasing hemorrhage risk. Normal bilirubin (1.0 mg/dL) and AST (34 units/L) reflect liver function, not clotting. Ammonia (55 mcg/dL) is normal, tied to encephalopathy, not biopsy safety. Low platelets impair hemostasis, often requiring transfusion or delay per procedural norms (e.g., AASLD), prioritizing safety unlike normal labs, this demands provider action, making it the critical value to report.