Nokea
The client is scheduled for a paracentesis. What should the nurse expect to do prior to the procedure?
- A. Insert an indwelling catheter
- B. Have the client void
- C. Keep the client NPO
- D. Administer an enema
Correct Answer: B
Rationale: Having the client void before paracentesis prevents bladder puncture during the procedure. Catheter insertion, NPO status, or enemas are not typically required.
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The nurse is caring for an adult who is receiving diphenoxylate hydrochloride with atropine sulfate (Lomotil) qid. What nursing assessment is essential while the client is receiving this medication?
- A. Monitor blood pressure hourly
- B. Assess respirations before administering drug
- C. Measure hourly urine output
- D. Do neuro checks every two hours
Correct Answer: B
Rationale: Lomotil can cause respiratory depression due to its opioid component, requiring respiratory assessment before administration.
The nursing care plan for a client with decreased adrenal function should include
- A. Encouraging activity
- B. Placing client in reverse isolation
- C. Limiting visitors
- D. Measures to prevent constipation
Correct Answer: C
Rationale: Limiting visitors. Limiting visitors reduces physical and emotional exertion, preventing an Addisonian crisis.
A woman is being seen in the physician's office for a medical complaint. When she is called to see the physician, she goes to the restroom and washes her hands over and over, missing her allotted time with the physician. How should the nurse deal with this woman?
- A. Send her home without seeing the doctor if she is not available when called
- B. Give her advance warning that she will be seeing the physician and tell her that if she needs to wash her hands, she should do so
- C. Interrupt her washing ritual and insist that she see the physician when it is her turn
- D. Give her a choice of seeing the physician or washing her hands
Correct Answer: B
Rationale: Advance warning accommodates possible OCD, allowing hand washing within a timeframe, ensuring she sees the physician. Sending home, interrupting, or forcing choices is less effective.
Diltiazem (Cardizem) 90 mg qid is prescribed for an adult who has angina. Which statement by the client indicates a need for further instruction?
- A. I will take the pills before meals and at bedtime.
- B. I will call my physician if the pain gets worse than it has been.
- C. If my heart rate is less than 70, I will not take the pill.
- D. I will get up slowly when I stand up.
Correct Answer: C
Rationale: Diltiazem is not typically withheld based on heart rate alone unless specified; this indicates a need for clarification on administration instructions.
The nurse understands that a priority goal of involuntary hospitalization of the severely mentally ill client is
- A. Re-orientation to reality
- B. Elimination of symptoms
- C. Protection from harm to self or others
- D. Return to independent functioning
Correct Answer: C
Rationale: Protection from harm to self or others. Involuntary hospitalization is required for individuals who are dangerous to themselves or others.