Nokea
The clinic nurse is reinforcing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?
- A. How to transmit the readings over the phone
- B. Keep a diary of activities and any symptoms experienced
- C. Refrain from exercising while wearing the monitor
- D. The monitor may be removed only when bathing
Correct Answer: B
Rationale: Keeping a diary of activities and symptoms correlates events with cardiac readings, aiding diagnosis. Transmitting readings is not client responsibility, and Holter monitors are typically worn continuously, including during bathing.
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The nurse is caring for several clients who are to have diagnostic tests. Which clients will receive similar instructions?
- A. The client who is having an upper GI series and the client who is having a lower GI series
- B. The client who is having a gallbladder sonogram and the client who is having a gallbladder x-ray
- C. The client who is having a barium enema and the client who is having a colonoscopy.
- D. The client who is having a gastroscopy and the client who is having a colonoscopy.
Correct Answer: C
Rationale: A barium enema and a colonoscopy both require a clear liquid diet and full bowel prep the day before. The only difference is that the client who is having a barium enema can have red liquids and the one who is having a colonoscopy cannot. The preparation for an upper GI series is NPO after midnight the night before. There is no preparation for a gallbladder sonogram. A gallbladder x-ray requires fat restriction the day before, taking iodine dye tablets, and NPO after midnight. The preparation for a gastroscopy is NPO after midnight the night before.
The nurse is reviewing recommended dietary modifications with the parents of a 6-month-old client with phenylketonuria. Which of the following information should the nurse include? Select all that apply.
- A. A low-phenylalanine diet is required
- B. Meat and dairy products should not be introduced into the diet
- C. Phenylketonuria is self-limiting and dietary modifications are temporary
- D. Specially prepared infant formula is necessary
- E. Tyrosine should be removed from the diet
Correct Answer: A,B,D
Rationale: Phenylketonuria requires a lifelong low-phenylalanine diet, avoiding meat and dairy, and using special formula to prevent neurological damage. It is not self-limiting, and tyrosine is needed, not removed.
The nurse should initiate discharge planning for a client
- A. When the client or family demonstrate readiness to learn self care modalities
- B. When informed that a date for discharge has been determined
- C. Upon admission to a hospital unit or the emergency room
- D. When the client's condition is stabilized on the assigned unit
Correct Answer: C
Rationale: Upon admission to a hospital unit or the emergency room. Early discharge planning ensures continuity of care with shorter hospital stays.
The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking Eskalith (lithium carbonate). Which of the following snacks would be best for the client?
- A. Potato chips
- B. Diet cola
- C. An apple
- D. A milkshake
Correct Answer: C
Rationale: Lithium carbonate can cause sodium depletion, and high-sodium snacks like potato chips should be avoided to prevent toxicity. Diet cola lacks nutritional value and may contain caffeine, which can exacerbate mania. An apple is a healthy, low-sodium snack that supports hydration and nutrition. A milkshake may be high in sugar or fat, which is less ideal.
Laboratory reference ranges
Potassium3.5-5.0 mEq/L(3.5-5.0 mmol/L)
INRNormal: 0.8-1.1Therapeutic: 1.5-4.0
The nurse recognizes which of the following factors as possibly contributing to a sentinel event?
- A. Administered warfarin to a client with an INR of 6.0
- B. Administered flumazenil to a client who overdosed on lorazepam
- C. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
- D. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
Correct Answer: A
Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.