Nokea
The client is scheduled for a computed tomography (CT) scan. Which question is most important for the nurse to ask before the procedure?
- A. On a scale of 1 to 10, how do you rate your pain?'
- B. Do you feel uncomfortable in enclosed spaces?'
- C. Are you allergic to seafood or iodine?'
- D. Have you signed a permit for this procedure?'
Correct Answer: C
Rationale: Iodine/seafood allergies are critical to assess before CT with contrast to prevent anaphylaxis. Claustrophobia, pain, and consent are secondary.
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The client with rheumatoid arthritis has been taking 15 to 20 extra-strength aspirin a day. Which additional statement that the client makes would be of greatest concern to the nurse?
- A. I sometimes have ringing in my ears.'
- B. I have a rash under my arms.'
- C. My fingers are swollen sometimes.'
- D. I don't have very much energy.'
Correct Answer: A
Rationale: Ringing in the ears (tinnitus) is a sign of aspirin toxicity, a serious concern requiring immediate attention.
The client has been flat in bed in traction for two weeks, and she is to be allowed out of bed for the first time today. What must the nurse be particularly alert for when getting the client out of bed?
- A. Renal complications
- B. Depression
- C. Orthostatic hypotension
- D. Skin breakdown
Correct Answer: C
Rationale: Prolonged bed rest increases the risk of orthostatic hypotension when first mobilizing, requiring careful monitoring.
The client is about to go to surgery but is still wearing a class ring. Which nursing action is most appropriate regarding care of the client's valuables?
- A. Put the ring in the bedside stand.
- B. Tape the ring to the client's finger.
- C. Give the ring to a security guard.
- D. Take the ring to the hospital safe.
Correct Answer: D
Rationale: Valuables like a ring should be secured in the hospital safe to prevent loss or theft during surgery. Leaving it in the bedside stand is insecure, taping it risks circulation issues, and giving it to a security guard is not standard protocol.
The nurse is caring for a client with a right below-the-knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implement first?
- A. Notify the client's surgeon immediately.
- B. Assess the client's blood pressure and pulse.
- C. Reinforce the dressing with additional dressing.
- D. Check the client's last hemoglobin and hematocrit levels.
Correct Answer: C
Rationale: Reinforcing the dressing controls bleeding, the priority in hemorrhage. Notifying the surgeon, assessing vitals, and checking labs are secondary.
The nurse is to administer nafcillin 500 mg intravenously to the client with osteomyelitis. A vial of 1 g of powdered nafcillin is to be reconstituted with 3.4 mL of 0.9% NaCl. How many milliliters should the nurse plan to administer?
- A. 1.7 mL
Correct Answer: A
Rationale: Rationale: 500 mg / 1,000 mg = x / 3.4 mL; x = 1.7 mL. The nurse should prepare 1.7 mL nafcillin (Nallpen).