Nokea
A nurse prepares a client for computed tomography (CT) scan with intravenous (IV) iodinated contrast. The nurse should take which action?
- A. Ask the client if they are allergic to shellfish
- B. Insert a 20-gauge peripheral vascular access device
- C. Obtain capillary blood glucose (CBG)
- D. Instruct the client to decrease their fluids after the procedure
Correct Answer: A
Rationale: Iodinated contrast carries a risk of allergic reactions, and a history of shellfish allergy may indicate iodine sensitivity, requiring further evaluation. A 20-gauge may be appropriate but isn’t the priority, CBG is irrelevant, and fluid restriction is incorrect.
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The nurse is caring for a client with increased intracranial pressure (ICP). The nurse plans on positioning the client's head of bed at
- A. 25 degrees.
- B. 30-40 degrees.
- C. 10-20 degrees.
- D. 5-10 degrees.
Correct Answer: B
Rationale: A 30-40 degree elevation optimizes cerebral venous drainage, reducing ICP. Lower angles may increase ICP, and 25 degrees is suboptimal.
The nurse is performing a focused physical assessment on a client's gastrointestinal system. Place the following actions in the order in which they should be performed, starting from first to last.
- A. Place pillows beneath the client's knees.
- B. Ask the client to void.
- C. Inspect the abdomen.
- D. Palpate the abdomen.
- E. Auscultate all four quadrants of the abdomen.
- F. Position the client supine with the knees bent and the arms at their side.
Correct Answer: B,F,C,E,D
Rationale: The correct order is: ask to void (B), position supine (F), inspect (C), auscultate (E), palpate (D). Voiding and positioning prepare the client, and inspection precedes auscultation to avoid altering bowel sounds. Pillows are not standard.
The nurse is observing a student nurse feed a client requiring aspiration precautions. The nurse should intervene if the student
- A. Asks the client to remain sitting upright for at least 30 to 60 minutes after a meal.
- B. Reminds the client to tilt their head backward when eating and drinking.
- C. Avoids mixing foods of different textures in the same mouthful.
- D. Places salt and pepper on the client's food at their request.
Correct Answer: B
Rationale: Tilting the head backward increases aspiration risk. Upright positioning, avoiding mixed textures, and seasoning food are appropriate.
A nurse is taking care of a client undergoing cerebral angiography. Which statement by the client would require immediate follow-up?
- A. I feel like I'm going to vomit.
- B. I hope my results are okay.
- C. It's getting a bit hot in here.
- D. My throat is getting a bit itchy, and my eyes are getting watery.
Correct Answer: D
Rationale: Itchy throat and watery eyes suggest an allergic reaction to the contrast dye, requiring immediate intervention. Nausea, hopefulness, and feeling warm are less urgent.
The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct in identifying which of the following medications can increase the risk for falls? Select all that apply.
- A. naproxen
- B. alprazolam
- C. bumetanide
- D. verapamil
- E. allopurinol
- F. thiamine
Correct Answer: B,C,D
Rationale: Alprazolam (benzodiazepine) causes sedation and dizziness, bumetanide (diuretic) can cause orthostatic hypotension, and verapamil (calcium channel blocker) can cause hypotension, all increasing fall risk. Naproxen, allopurinol, and thiamine do not significantly contribute to falls.