Nokea
The nurse is accompanying the client to the diagnostic imaging unit for a magnetic resonance imaging (MRI). Which action by the nurse is most important prior to the test?
- A. Instruct the client that the scanner makes loud clanging.
- B. Calculate drop per minute for intravenous fluids and infuse by gravity.
- C. Support client, if nervous, by words of encouragement.
- D. Ensure that the client does not ingest fluids in the waiting area.
Correct Answer: B
Rationale: It is most important that the nurse calculate the drip rate of the intravenous fluids because the client will not be able to have an electrical or mechanical pump operating during the MRI. The MRI electrical charges during the test can affect the pump. It is also important to advise the client of the loud noises and offer support to the client. Water is typically not available in the waiting area prior to testing.
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The nurse is caring for a client following gastrointestinal diagnostic testing. The client verbalizes feeling shame due to having frequent gas. Which nursing suggestion is best?
- A. Having gas following the procedure is normal. Expel the gas to decrease discomfort.
- B. Do not be ashamed. Everyone has gas following the procedure.
- C. The nursing staff is used to having clients with gas due to the procedure completed.
- D. Nurses anticipate that client will have gas following the procedure and provide privacy.
Correct Answer: A
Rationale: The nurse is correct to tell the client that this experience is normal and encourage the client to release the gas to decrease pain and discomfort. Providing information relieving the embarrassment and stating the benefit of the action is most helpful.
The nurse is caring for a geriatric client at a long-term care facility. When administering the client's medications, which age-related change(s) of the client is anticipated? Select all that apply.
- A. Increased saliva causing drooling
- B. Decreased motility in the esophagus
- C. A weak gag reflex
- D. Increased amount of gastric secretions
- E. Decreased elasticity of the rectal wall
Correct Answer: B,C,E
Rationale: Age-related considerations when administering medications to a geriatric client include administering medications slowly and allowing time between medications due to a decreased motility in the esophagus. Additionally, the client has a weakened gag reflex, which may cause the client to choke. The client has a decreased elasticity of the rectal wall potentially causing fecal incontinence. Geriatric clients have a decrease in saliva production requiring water with oral medication administration. There is also a decrease in the amount of gastric secretions, which could produce nausea.
The nurse is preparing to examine the abdomen of a client with reports of nausea and vomiting. What action would the nurse perform first?
- A. Palpation
- B. Inspection
- C. Auscultation
- D. Percussion
Correct Answer: B
Rationale: When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.
Which nursing instruction is correct to provide the client following a barium enema?
- A. The client will maintain a low residue diet.
- B. The stools may be a white or clay colored.
- C. Sips of fluid may be increased if tolerated.
- D. An enema will be used to clear the bowel.
Correct Answer: B
Rationale: It is important to instruct the client that it is normal to have a white- or clay-colored stool following the barium enema. The client should report the color of the stool to the nurse. A progression of clay-colored stools to brown-colored stools should be noted. The client is prescribed a low-residue diet before the procedure. An increased fluid intake is offered to eliminate the barium from the bowel. The client is encouraged to move the bowel independently.
The nurse is working in a diagnostic testing unit focusing on gastrointestinal studies. For which testing procedure is the nurse correct to assess the gag reflex before offering fluids?
- A. Esophagogastroduodenoscopy
- B. Sigmoidoscopy
- C. Peritoneoscopy
- D. Colonoscopy
Correct Answer: A
Rationale: The nurse is correct to assess the gag reflex prior to offering fluids for a client having an esophagogastroduodenoscopy (EGD). The other options are lower gastrointestinal studies typically requiring a bowel preparation.