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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.
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The doctor has ordered an IV of magnesium sulfate for a G1 P0 with preeclampsia. Which of the following symptoms is an expected side effect of magnesium sulfate?
- A. Oliguria
- B. Hypersomnolence
- C. Hyporeflexia
- D. Bradypnea
Correct Answer: C
Rationale: Hyporeflexia is an expected side effect of magnesium sulfate, used to monitor for toxicity in preeclampsia treatment.
The nurse is caring for a client with a history of headaches who has come to the clinic reporting a 'bad migraine.' The client was able to provide a full health history while waiting to be seen. Which finding is most concerning?
- A. Blood pressure of 136/88 mm Hg
- B. Flat affect and drowsiness
- C. Nausea and poor appetite
- D. Respiratory rate of 12/min
Correct Answer: B
Rationale: Flat affect and drowsiness in a migraine are atypical and may indicate a more serious condition like a neurological event, requiring urgent evaluation. Nausea and poor appetite are common in migraines, and the BP and respiratory rate are within normal limits.
The nurse is reinforcing meal planning teaching to a group of clients with celiac disease. Which meal is appropriate for the nurse to include?
- A. Baked salmon with rice, steamed vegetables, and dinner roll
- B. Breaded pork chops, corn on the cob, and steamed snow peas
- C. Grilled chicken, green beans, and mashed potatoes
- D. Spaghetti with Italian tomato sauce and meatballs
Correct Answer: C
Rationale: Grilled chicken, green beans, and mashed potatoes are gluten-free, suitable for celiac disease. Dinner rolls, breaded pork chops, and spaghetti contain gluten, which must be avoided.
The nurse is assisting with the removal of a client’s chest tube. Which of the following actions should the nurse take? Select all that apply.
- A. Ensure the client is given an analgesic 30-60 minutes before tube removal
- B. Instruct the client to breathe in, hold it, and bear down while the tube is being removed
- C. Place the client in the Trendelenburg position
- D. Prepare a sterile airtight petroleum jelly gauze dressing
- E. Provide the health care provider with sterile suture removal equipment
Correct Answer: A,B,D,E
Rationale: Analgesics reduce pain, Valsalva maneuver (bear down) prevents air entry, petroleum gauze seals the site, and suture equipment is needed. Trendelenburg is not indicated for chest tube removal.
The nurse is caring for assigned clients. The nurse should first check the client with
- A. sickle cell disease who has new onset pain rated as 9 on a scale of 0-10
- B. pneumonia who has a temperature of 100.6°F (38.1°C) and is receiving IV antibiotics
- C. Graves’ disease who has a heart rate of 110/min and a blood pressure of 122/85 mm Hg
- D. diabetes mellitus who has an elevated serum glucose level and is requesting insulin lispro prior to a meal
Correct Answer: A
Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.