Nokea
The nurse is caring for a client with cholelithiasis and acute cholecystitis. The client suddenly vomits 250 mL of greenish-yellow emesis and reports severe right upper quadrant pain with radiation to the right shoulder. Which intervention would have the highest priority?
- A. Administer promethazine suppository
- B. Initiate NPO status
- C. Insert nasogastric tube set to low suction
- D. Obtain prescription for pain medication
Correct Answer: B
Rationale: Acute cholecystitis with vomiting and severe pain suggests gallbladder inflammation or obstruction, requiring immediate cessation of oral intake (NPO status, B) to prevent further stimulation and complications like perforation. Promethazine (A) and pain medication (D) are supportive but secondary. A nasogastric tube (C) may be considered later but is not the priority.
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During an initial prenatal visit, the practical nurse is reviewing the history of a client at 10 weeks gestation. Which finding is a priority to report to the registered nurse?
- A. Client cares for a pet dog and a few outdoor cats
- B. Client has gained 4 lb (1.8 kg) during the pregnancy so far
- C. Client reports a nonodorous, milky white vaginal discharge
- D. Client swims in a pool for exercise three times per week
Correct Answer: A
Rationale: Pet cats (A) pose a toxoplasmosis risk, which can cause fetal harm, requiring immediate education and possible testing. Weight gain (B) is normal, milky discharge (C) is typical in pregnancy, and swimming (D) is safe.
A client diagnosed with endometrial cancer is receiving brachytherapy. Which interventions should the nurse anticipate for this client? Select all that apply.
- A. Cluster care to limit each staff member's time in the room
- B. Instruct the client to be up and around in the room but not to leave the room
- C. Remind family members and visitors to limit close contact with the client
- D. Use protective shielding, if available, when providing direct client care
- E. Wear a radiation badge while in the client's room to measure radiation exposure
Correct Answer: A,C,D,E
Rationale: Brachytherapy involves internal radiation, requiring precautions to minimize exposure. Clustering care (A) reduces staff exposure time. Limiting visitor contact (C) protects others from radiation. Protective shielding (D) and radiation badges (E) ensure safety and monitor exposure. Ambulation (B) is restricted to prevent dislodging the radiation source.
A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?
- A. Encourage the visitor to lie down to see if symptoms change
- B. Initiate protocol to assist the visitor to the emergency department
- C. Proceed to take the visitor's blood pressure
- D. Suggest that the visitor call the health care provider
Correct Answer: B
Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (B) ensures timely care. Lying down (A), taking blood pressure (C), or calling a provider (D) delays critical intervention.
A client with gout who was started on allopurinol a week ago calls the health care provider’s office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up?
- A. Also takes ibuprofen for pain
- B. Frequency of urination has increased
- C. Mild red rash has developed over torso
- D. Nausea occurs after each dose
Correct Answer: C
Rationale: A rash (C) may indicate a hypersensitivity reaction to allopurinol, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate follow-up. Ibuprofen (A), urination (B), and nausea (D) are less urgent.
A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to
- A. Promote the client's comfort
- B. Reduce the drying time
- C. Decrease irritation to the skin
- D. Improve venous return
Correct Answer: D
Rationale: Elevating the leg both improves venous return and reduces swelling. Client comfort will be improved as well.