Nokea
After an intravenous pyelogram (IVP), the nurse should not include incorporating which of the following measures into the client's plan of care?
- A. Maintaining bed rest.
- B. Encouraging adequate fluid intake.
- C. Assessing for hematuria.
- D. Administering a laxative.
Correct Answer: D
Rationale: Administering a laxative is unnecessary post-IVP, as it does not aid recovery or contrast excretion, unlike fluid intake or hematuria assessment.
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The nurse is applying a hand mitt restraint for a client with pruritis (see figure). The nurse should be:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: A physician's order is required for restraints to ensure legal and ethical use, prioritizing patient safety and preventing scratching in pruritus.
The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia?
- A. 59 mg/dL.
- B. 75 mg/dL.
- C. 108 mg/dL.
- D. 119 mg/dL.
Correct Answer: A
Rationale: A blood glucose level of 59 mg/dL is below the normal range (<70 mg/dL) and indicates hypoglycemia, requiring immediate intervention.
The client's blood urea nitrogen (BUN) concentration is elevated in acute renal failure. What is the likely cause of this finding?
- A. Fluid retention.
- B. Hemolysis of red blood cells.
- C. Below-normal metabolic rate.
- D. Reduced renal blood flow.
Correct Answer: D
Rationale: Reduced renal blood flow impairs urea excretion, causing elevated BUN levels in acute renal failure.
The client with an above-the-knee amputation is to use crutches while his prosthesis is being adjusted. In which of the following exercises should the nurse instruct the client to best prepare him for using crutches?
- A. Abdominal exercises.
- B. Isometric shoulder exercises.
- C. Quadriceps setting exercises.
- D. Triceps stretching exercises.
Correct Answer: B
Rationale: Isometric shoulder exercises strengthen the upper body, essential for crutch walking.
The nurse should monitor the surgical client closely for which clinical manifestation with the administration of naloxone (Narcan)?
- A. Dizziness.
- B. Biliary colic.
- C. Bleeding.
- D. Urine retention.
Correct Answer: A
Rationale: Naloxone can cause dizziness due to rapid reversal of opioid effects, leading to autonomic changes. This is a common side effect to monitor in surgical clients.