Nokea
It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client?
- A. You must shampoo your hair tonight to remove all oil and dirt.
- B. You may drink fluids until midnight, but after that drink nothing until the scan is completed.
- C. You will have some hair shaved to attach the small electrode to your scalp.
- D. You will need to hold your head very still during the examination.
Correct Answer: D
Rationale: Holding the head still during a CT scan is essential to obtain clear images. Shampooing, fasting, or shaving hair for electrodes are not required for a non-contrast head CT.
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Which of the following is the most important goal of nursing care for a client who is in shock?
- A. Manage fluid overload.
- B. Manage increased cardiac output.
- C. Manage inadequate tissue perfusion.
- D. Manage vasoconstriction of vascular beds.
Correct Answer: C
Rationale: Shock is characterized by inadequate tissue perfusion due to insufficient blood flow. The primary nursing goal is to restore perfusion to vital organs through fluid resuscitation, medications, or other interventions. Fluid overload, increased cardiac output, and vasoconstriction are not primary concerns.
A client had a colectomy 8½ hours ago. She has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
- A. Check that the family is comfortable.
- B. Assess vital signs following the use of morphine.
- C. Dim the lights in the room.
- D. Increase nasal oxygen from 2 to 3 L.
Correct Answer: B
Rationale: Morphine can cause respiratory depression or hypotension. Assessing vital signs after PCA use ensures the client's safety and detects adverse effects promptly.
At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
- A. Report the 24-hour drainage amount at 12. Clamp the T-tube.
- B. Evaluate the tube for patency.
- C. Irrigate the T-tube.
- D. Continue to monitor the drainage.
Correct Answer: C
Rationale: The T-tube should drain approximately 300 to 500 mL in the fi rst 24 hours and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 8 a.m., the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without an order.
The nurse is caring for a client in skeletal traction for a femoral fracture. Which assessment should be prioritized?
- A. Skin integrity at pin sites.
- B. Room temperature control.
- C. Frequency of bowel movements.
- D. Client's emotional status.
Correct Answer: A
Rationale: Pin site infections are a common complication in skeletal traction, requiring prioritized assessment.
Which assessment is most important for a client with a traumatic brain injury?
- A. Glasgow Coma Scale.
- B. Blood glucose levels.
- C. Electrolyte panel.
- D. Pain assessment.
Correct Answer: A
Rationale: The Glasgow Coma Scale is critical to assess neurological status and guide management in traumatic brain injury.