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A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure?
- A. Soon those shock waves will get rid of my gallstones.
- B. I’ll have a camera put down my throat so they can see my gallbladder.
- C. They are going to use dye to examine my gallbladder and ducts.
- D. They’ll put medication into my gallbladder to dissolve the stones.
Correct Answer: C
Rationale: The correct answer is C because the client's statement indicates an understanding of the procedure. Oral cholangiogram involves injecting dye to visualize the gallbladder and ducts. Choice A is incorrect as shock waves are used in lithotripsy, not oral cholangiogram. Choice B is incorrect as the procedure involves dye, not a camera down the throat. Choice D is incorrect as medication is not used in this procedure.
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The nurse is assigned to care for a client who is 2 days postoperative after an above-the-knee amputation of the right leg. The nurse plans to implement which measure to prevent hip contractures?
- A. Maintain the client in a supine position.
- B. Maintain a high-Fowler’s position when the client is in bed.
- C. Elevate the stump on a pillow.
- D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Correct Answer: D
Rationale: Correct Answer: D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Rationale: Positioning the client on the abdomen helps prevent hip contractures by stretching the hip flexors and maintaining hip extension. This position also helps to prevent hip adduction contractures, which can occur due to prolonged positioning on the back. By alternating positions, the client's hip joint is kept in a more functional and extended position, reducing the risk of contractures.
Summary of other choices:
A: Maintaining the client in a supine position does not actively prevent hip contractures and may even contribute to hip flexion contractures.
B: Maintaining a high-Fowler's position when the client is in bed does not address hip extension and may lead to hip flexion contractures.
C: Elevating the stump on a pillow is important for stump care but does not specifically target prevention of hip contractures.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
- A. Irregular pulse.
- B. Persistent fatigue.
- C. Dependent edema.
- D. Slurred speech.
Correct Answer: D
Rationale: The correct answer is D: Slurred speech. Slurred speech can be a sign of a potential stroke, which can occur in patients with atrial fibrillation due to the risk of blood clots forming in the heart. This finding should be reported immediately to the provider for further evaluation and intervention to prevent further complications. Monitoring for slurred speech helps in early detection and prompt management of a potential stroke.
Other choices such as A: Irregular pulse, B: Persistent fatigue, and C: Dependent edema are common in patients with heart failure and atrial fibrillation but are not immediate concerns requiring urgent intervention like slurred speech indicating a potential stroke.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?
- A. Does drinking coffee or ingesting chocolate seem related to the episodes?
- B. Does being exposed to heat seem to cause the episodes?
- C. Do the signs and symptoms occur while you are asleep?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: A
Rationale: The correct answer is A: Does drinking coffee or ingesting chocolate seem related to the episodes? This question is relevant because caffeine and chocolate are known triggers for Raynaud's disease due to their vasoconstrictive properties. By asking about these specific triggers, the nurse can gather important information to help identify potential causes of the client's symptoms.
Choice B is incorrect because exposure to heat typically alleviates symptoms of Raynaud's disease rather than causing them. Choice C is irrelevant as Raynaud's symptoms typically occur when the individual is exposed to cold or experiencing stress, not while asleep. Choice D is also incorrect as injuries limiting activity levels are not directly related to Raynaud's disease triggers.
A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?
- A. Insert a nasogastric (NG) tube.
- B. Ask the client about the precipitating events.
- C. Obtain vital signs.
- D. Complete a head-to-toe assessment.
Correct Answer: C
Rationale: The correct answer is C: Obtain vital signs. The first step in triaging a patient with gastrointestinal bleeding is to assess their vital signs to determine the severity of the situation. Vital signs, such as blood pressure, heart rate, respiratory rate, and oxygen saturation, provide crucial information about the patient's condition and help prioritize the level of care needed. This immediate assessment allows the triage nurse to identify any signs of shock or instability, guiding further interventions and treatment. Inserting an NG tube (choice A) or completing a head-to-toe assessment (choice D) can wait until the patient's vital signs are stable and the immediate risk is addressed. Asking about precipitating events (choice B) may provide important information but is not as urgent as assessing vital signs in this critical situation.
A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?
- A. Remove the vest daily to inspect the client’s skin integrity.
- B. Check that the halo jacket is snug against the client’s skin.
- C. Provide range of motion to the client’s neck.
- D. Monitor the client for an elevated temperature.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client for an elevated temperature. This is important because an elevated temperature could indicate infection, which is a significant concern when a client has a halo fixation device. Removing the vest daily (Choice A) is not recommended as it can compromise the stability of the device. Checking that the halo jacket is snug (Choice B) is important, but monitoring for an elevated temperature is a higher priority. Providing range of motion to the client's neck (Choice C) is contraindicated with a halo device as it can cause serious injury.