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A nurse is teaching a client about cystoscopy preparation. What instruction should be included?
- A. Fast for 8 hours before the procedure.
- B. Drink plenty of water before the test.
- C. Expect to stay overnight in the hospital.
- D. Empty the bladder before the procedure.
Correct Answer: D
Rationale: Emptying the bladder ensures a clear view during cystoscopy and reduces discomfort.
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The nurse is caring for a client who ingested a lethal dose of aspirin (ASA). Which assessment finding is most concerning?
- A. Pulmonary edema
- B. Tinnitus
- C. Nausea and vomiting
- D. Tachycardia
Correct Answer: A
Rationale: Pulmonary edema is life-threatening and indicates severe aspirin toxicity, potentially leading to respiratory failure.
The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply.
- A. Monitoring vital signs once a shift.
- B. Weighing the client daily.
- C. Changing the central venous line dressing daily.
- D. Monitoring the I.V. infusion rate hourly.
- E. Taping all I.V. tubing connections securely.
Correct Answer: B,C,D,E
Rationale: For a client on TPN, daily weight monitoring (B), daily dressing changes (C), hourly infusion rate checks (D), and securing tubing connections (E) are critical to prevent complications like infection or fluid imbalance. Vital signs once a shift (A) is insufficient; more frequent monitoring is needed. CN: Pharmacological and parenteral therapies; CL: Create
A client refuses to remove a religious necklace before surgery despite hospital policy. The nurse's best response is:
- A. Remove the necklace during transport.
- B. Tape the necklace securely to the client's chest.
- C. Insist the client comply with policy.
- D. Notify the surgeon to cancel the procedure.
Correct Answer: B
Rationale: Taping the necklace securely respects the client's beliefs while ensuring safety by preventing the item from interfering with the surgical field.
Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops?
- A. Inserting a nasogastric (NG) tube.
- B. Restricting fluids to 1,000 mL/day.
- C. Administering I.V. salt-poor albumin.
- D. Implementing a low-protein diet.
Correct Answer: D
Rationale: A low-protein diet (D) reduces ammonia production in hepatic encephalopathy. NG tubes (A), fluid restriction (B), and albumin (C) are not primary interventions.
The client with Addison's disease is taking glucocorticoids. Which of the following statements indicates that the client understands how to take the medication?
- A. Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage.'
- B. My need for glucocorticoids will stabilize and I will be able to take a predetermined dose once a day.'
- C. Glucocorticoids are cumulative, so I will take a dose every third day.'
- D. I must take a dose every 6 hours to ensure consistent blood levels of glucocorticoids.'
Correct Answer: A
Rationale: Glucocorticoid needs vary with stress, requiring dose adjustments in Addison's disease to prevent adrenal crisis.