Nokea
The client is scheduled to have an intravenous cholangiogram. Before the procedure, the nurse should assess the patient for:
- A. Shellfish allergies
- B. Reactions to blood transfusions
- C. Gallbladder disease
- D. Egg allergies
Correct Answer: A
Rationale: Iodinated contrast used in cholangiograms can cause reactions in patients with shellfish or iodine allergies due to potential cross-reactivity.
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Which activity is suitable for a client who suffered an uncomplicated myocardial infarction (MI) 2 days ago?
- A. Sitting in the bedside chair for 15 minutes three times a day
- B. Remaining on strict bed rest with bedside commode privileges
- C. Ambulating in the room and hall as tolerated
- D. Sitting on the bedside for 5 minutes three times a day with assistance
Correct Answer: A
Rationale: Sitting in a chair for short periods is appropriate 2 days post-MI to promote circulation and prevent complications, while ambulation is too strenuous.
A client who just delivered is concerned about her neonate's Apgar scores of 7 at 1 minute and 8 at 5 minutes. She has been told a score lower than 9 is associated with learning disabilities. Which response is best?
- A. Your infant is fine. Don't worry.
- B. Apgar scores indicate a need for extra medical care at birth. Your baby's score of 7 is fine.
- C. There are many good special education programs available I can recommend.
- D. I'll ask the physician to speak with you.
Correct Answer: B
Rationale: Apgar scores of 7 and 8 are within normal limits, indicating no immediate need for extra care, and this response addresses the mother's concern accurately without dismissing it.
Which cephalic presentation is most common during delivery of a neonate?
- A. Vertex
- B. Face
- C. Military
- D. Brow
Correct Answer: A
Rationale: Vertex presentation (A), with the head flexed and occiput leading, is the most common (95%) during delivery.
The nurse is caring for a client on airborne precautions. Which of the following would the nurse expect to see in the client's medical record?
- A. measles
- B. influenza
- C. Lyme disease
- D. herpes simplex
Correct Answer: A
Rationale: Measles requires airborne precautions due to its highly contagious nature via respiratory droplets, unlike the other conditions listed.
A client is admitted with disseminated herpes zoster. According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions due to the risk of varicella-zoster virus transmission through respiratory droplets and contact.