Nokea
Because an adult is scheduled for a cystoscopy, the nurse should plan to do which of the following immediately prior to the procedure?
- A. Keep the client NPO for eight hours
- B. Ask the client about claustrophobia
- C. Ask the client about allergies to shellfish
- D. Encourage fluids
Correct Answer: C
Rationale: Cystoscopy may involve iodine-based contrast; shellfish allergies suggest iodine sensitivity, requiring verification. NPO is not needed, claustrophobia is irrelevant, and fluids are not prioritized immediately before.
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A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?
- A. Provide the ordered humidified oxygen via mask
- B. Suction the mouth and the nose
- C. Check the mouth and radial pulse
- D. Start the ordered intravenous fluids
Correct Answer: C
Rationale: Check the mouth and radial pulse. Assessing airway, breathing, and circulation is the first step in treating toxic ingestion to stabilize the client.
The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?
- A. Auscultate breath sounds to assess for crackles
- B. Monitor for >50 mL/hr urine output
- C. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15
- D. Press over the tibia to assess for pitting edema
Correct Answer: D
Rationale: Pitting edema indicates fluid overload, a potential mannitol complication due to fluid shifts. High urine output is expected, and improving Glasgow Coma Scale is a therapeutic effect.
The afternoon following a thyroidectomy, the client experiences all of the following. Which one indicates to the nurse that the client is experiencing a serious complication?
- A. A sore throat
- B. Pain at the surgical site
- C. Temperature of 100.2°F
- D. Sudden hoarseness
Correct Answer: D
Rationale: Sudden hoarseness post-thyroidectomy may indicate vocal cord paralysis or hematoma compressing the airway, a serious complication requiring immediate attention. Sore throat, surgical pain, or mild fever are expected.
The nurse is caring for a client with diabetic ketoacidosis (DKA). Which of the following acid-base imbalances would the nurse expect to assess in this client?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: DKA causes metabolic acidosis due to excess ketone production from fat breakdown. Alkalosis and respiratory imbalances are not typical in DKA.
The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience
- A. high fever
- B. nausea
- C. face and neck edema
- D. night sweats
Correct Answer: B
Rationale: nausea. Because the client with Hodgkin's disease is usually healthy when therapy begins, the nausea is especially troubling.