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The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. To prepare the client for this procedure, the nurse should explain to the client that:
- A. Fluid and food will be withheld the morning of the examination.
- B. A tranquilizer will be given before the examination.
- C. An enema will be given before the examination.
- D. No special preparation is required for the examination.
Correct Answer: D
Rationale: A KUB radiograph requires no special preparation, as it is a non-invasive imaging test to locate renal calculi.
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A client with angina has been taking nifedipine. The nurse should teach the client to:
- A. Monitor blood pressure monthly.
- B. Perform daily weights.
- C. Inspect gums daily.
- D. Limit intake of green leafy vegetables.
Correct Answer: C
Rationale: Nifedipine, a calcium channel blocker, can cause gingival hyperplasia. Daily gum inspection helps detect this side effect early.
Contraindications to the administration of tissue plasminogen activator (t-PA) include which of the following?
- A. Age greater than 60 years.
- B. History of cerebral hemorrhage.
- C. History of heart failure.
- D. Cigarette smoking.
Correct Answer: B
Rationale: A history of cerebral hemorrhage is an absolute contraindication to t-PA due to the risk of bleeding. Age, heart failure, and smoking are not contraindications.
A client is recovering from an abdominal-perineal resection. Which of the following measures would most effectively promote wound healing after the perineal drains have been removed?
- A. Taking sitz baths several times a day.
- B. Applying a moist heat pack to the wound.
- C. Performing perineal irrigations.
- D. Packing the wound with sterile gauze.
Correct Answer: A
Rationale: Sitz baths promote wound healing by improving circulation, reducing inflammation, and keeping the perineal area clean after an abdominal-perineal resection. Moist heat packs, irrigations, or packing are less effective or not standard for this purpose. CN: Physiological adaptation; CL: Synthesize
A client with a suspected diagnosis of Hodgkin's disease is to have a lymph node biopsy. Which action is correct for handling the lymph node biopsy specimen for histologic examination for this client?
- A. Maintain sterile technique.
- B. Use a mask, gloves, and a gown when assisting with the procedure.
- C. Place the specimen in a container and send it to the laboratory when someone is available to take it.
- D. Call for a laboratory technician to assist the physician.
Correct Answer: C
Rationale: The lymph node biopsy specimen should be placed in a container and sent to the laboratory promptly to preserve tissue integrity for histologic examination. Sterile technique is maintained during the procedure, not for handling afterward, and masks/gowns or technician assistance are not required for transport.
If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock, which characteristic sign should the nurse expect to observe?
- A. Oliguria.
- B. Bradycardia.
- C. Elevated blood pressure.
- D. Fever.
Correct Answer: A
Rationale: Cardiogenic shock causes decreased cardiac output, leading to reduced renal perfusion and oliguria (low urine output). Bradycardia, elevated BP, and fever are not typical signs.