Nokea
The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation?
- A. Ensuring adequate fluid intake on the day of the test.
- B. Preparing the client for the possibility of bladder, the client is history for allergy to iodine.
- C. Determining when the client last had a bowel movement.
Correct Answer: B
Rationale: Checking for iodine allergy is critical for IVP due to the use of iodine-based contrast, which can cause severe allergic reactions.
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A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss?
- A. Hypotension.
- B. Decreased serum potassium level.
- C. Rapid, deep respirations.
- D. Warm, dry skin.
Correct Answer: C
Rationale: Rapid, deep respirations (Kussmaul respirations) in diabetic ketoacidosis are a compensatory mechanism for acidosis, leading to significant fluid loss through hyperventilation.
Which of the following items of documentation is not required for the nurse to have on the chart before the client is transported to the operating suite?
- A. Operative consent.
- B. History and physical information.
- C. Laboratory test results.
- D. Anesthesia note.
Correct Answer: D
Rationale: The anesthesia note is completed intraoperatively or post-procedure by the anesthesiologist. The other documents are required preoperatively to ensure informed consent and medical readiness.
The nurse is caring for a client who has influenza. Which of the following prescriptions may be prescribed by the primary healthcare provider (PHCP)?
- A. Valacyclovir
- B. Oseltamivir
- C. Azithromycin
- D. Omeprazole
Correct Answer: B
Rationale: Oseltamivir is an antiviral medication used to treat influenza. Choice A (valacyclovir) is for herpes, Choice C (azithromycin) is an antibiotic, and Choice D (omeprazole) is a proton pump inhibitor, none of which treat influenza.
Three hours ago a client was thrown from a car into a ditch, and he is now admitted to the emergency department in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. For which signs and symptoms should the nurse be especially alert?
- A. Infection
- B. Deformity
- C. Shock
- D. None of the above
Correct Answer: C
Rationale: An open fracture increases the risk of infection and deformity, but shock is a critical systemic complication that can develop rapidly due to blood loss or pain, requiring vigilant monitoring.
On the second day following an abdominal perineal resection, the nurse notes that the wound edges aren't approximated and one half the incision has torn apart. The nurse should immediately take what action?
- A. Flush the wound with sterile water.
- B. Apply an abdominal binder.
- C. Cover the wound with a sterile dressing moistened with normal saline.
- D. Apply strips of tape.
Correct Answer: C
Rationale: Covering the wound with a sterile dressing moistened with normal saline protects the open wound from infection and keeps it moist until further medical evaluation. Flushing, applying a binder, or using tape are inappropriate without addressing the dehiscence first. CN: Physiological adaptation; CL: Synthesize