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The nurse is preparing a client for a bone scan to evaluate bone health. Which instruction is appropriate?
- A. Avoid caffeine 24 hours before the test.
- B. Drink plenty of water after the scan.
- C. Fast for 8 hours before the procedure.
- D. Wear tight clothing during the scan.
Correct Answer: B
Rationale: Drinking water post-scan helps flush the radioactive tracer used in a bone scan.
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The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug?
- A. The drug's execution peaks in 2 hours.
- B. Maximum dosage is not achieved until 3 to 4 days after starting the medication.
- C. Effects of the drug continue for 4 to 5 days after discontinuing the medication.
- D. Protamine sulfate is the antidote for warfarin.
- E. I should have my blood levels tested periodically.
Correct Answer: B,C,E
Rationale: Warfarin's maximum effect takes 3-4 days (B), its effects persist 4-5 days after stopping (C), and periodic blood tests (e.g., INR) are required (E). Peak action is not 2 hours, and protamine sulfate is the antidote for heparin, not warfarin.
Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? The client will:
- A. Maintain a fluid intake of 800 mL every 24 hours.
- B. Experience chills only once a day.
- C. Cough productively without chest discomfort.
- D. Experience less nasal obstruction and discharge.
Correct Answer: D
Rationale: An expected outcome for recovery from an upper respiratory tract infection is reduced nasal obstruction and discharge, indicating resolution of inflammation and infection. A fluid intake of 800 mL is too low; 1,500–2,000 mL is more appropriate. Chills are not a typical measure of recovery. Productive coughing without discomfort may occur but is less specific than reduced nasal symptoms.
After an inguinal herniorrhaphy, the nurse should assess the client carefully for which of the following likely complications?
- A. Pneumonia.
- B. Deep vein thrombosis.
- C. Paralytic ileus.
- D. Urine retention.
Correct Answer: D
Rationale: Urine retention is a likely complication after inguinal herniorrhaphy due to anesthesia, pain, or surgical manipulation near the bladder. Pneumonia, deep vein thrombosis, and paralytic ileus are less specific to this surgery. CN: Physiological adaptation; CL: Analyze
A 60-year-old female with chronic cancer pain has been receiving opiates for 4 months. She rated her pain as an 8 on a 10-point scale before starting the opioid medication. She has just had a thorough examination with no new evidence of increased disease, yet her pain is close to 8 again. The most likely explanation for her increasing pain is:
- A. Development of an addiction to the opioids.
- B. Tolerance to the opioid.
- C. Withdrawal from the opioid.
- D. Placebo effect has decreased.
Correct Answer: B
Rationale: Tolerance to opioids is the most likely explanation, as the body adapts to the medication over time, reducing its effectiveness and requiring a dose adjustment.
What is the nurse's best action for a client with a suspected stroke and aphasia?
- A. Speak loudly.
- B. Use simple phrases.
- C. Write all instructions.
- D. Avoid communication.
Correct Answer: B
Rationale: Using simple phrases supports communication in stroke patients with aphasia.