Nokea
A client is admitted to the neurology unit for a myelogram.
It would be MOST important for the nurse to ask which of the following questions?
- A. Do you have any allergies?'
- B. Have you been drinking lots of fluids?'
- C. Are you wearing any metal objects?'
- D. Are you taking medication?'
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to a myelogram. (1) correct-dye is injected into subarachnoid space before an x-ray of spinal cord and vertebral column to assist in identifying spinal lesions; if client is allergic to dye, there is a major safety issue (2) important that client drink extra fluids after the Test to replace the CSF lost during Test (3) appropriate for magnetic resonance imaging (MRI) (4) obtain history of medication that can lower seizure threshold (phenothiazines, neuroleptics)
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The nurse is preparing a client for a skin biopsy.
Which of the following client statements should the nurse report to the physician?
- A. I've been taking aspirin for my sore knees.'
- B. Using lotion has helped my dry skin.'
- C. I went to the tanning salon yesterday.'
- D. I had a big breakfast this morning.'
Correct Answer: A
Rationale: Strategy: Determine how the statements relate to skin biopsy. (1) correct-aspirin compounds can increase bleeding time and should not be taken prior to a surgical procedure (2) does not affect the accuracy or results of the biopsy (3) does not affect the accuracy or results of the biopsy (4) does not affect the accuracy or results of the biopsy
The nurse is caring for a client who is postoperative day 1 after a prostatectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Urinary output of 200 mL/hour.
- D. Blood-tinged urine.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-prostatectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, high urinary output, and blood-tinged urine are normal on day 1.
A client that has stage III pressure ulcer of the sacrum with foul smelling purulent drainage.
The nurse should intervene in which of the following situations?
- A. The LPN/LVN enters the room wearing a gown and gloves.
- B. The nursing assistant enters the room wearing a mask.
- C. The client's family brings him a milkshake.
- D. The staff lifts the client to reposition him.
Correct Answer: B
Rationale: Strategy: 'Nurse should intervene' indicates an incorrect behavior. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) contact precautions required for infected decubitus ulcer; private room if possible (2) correct-masks not needed and doors do not need to be closed (3) maintain positive nitrogen balance, should offer high protein diet with protein supplements (4) lifting prevents shearing force
The nurse is supervising care given to a group of patients on the unit. The nurse observes a staff member entering a patient's room wearing gown and gloves. The nurse knows that the staff member is caring for which of the following patients?
- A. An 18-month-old with respiratory syncytial virus.
- B. A 4-year-old with Kawasaki disease.
- C. A 10-year-old with Lyme's disease.
- D. A 16-year-old with infectious mononucleosis.
Correct Answer: A
Rationale: acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children
The nurse is caring for a client who is to be on bed rest for two weeks. What should the nurse do to prevent atelectasis?
- A. Encourage the client to deep breathe and cough every two hours
- B. Encourage the client to flex and extend her feet every two hours
- C. Apply antiembolism stockings as ordered
- D. Perform range-of-motion exercises several times a day
Correct Answer: A
Rationale: Deep breathing and coughing expand the lungs, preventing atelectasis in bedridden clients. Foot exercises, stockings, and ROM prevent other complications but not atelectasis.