Nokea
The nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
- A. The client lies still.
- B. The client wears a watch and wedding
- C. The client asks questions. band.
- D. the client hears thumping sounds.
Correct Answer: B
Rationale: The correct answer is B: The client wears a watch and wedding band. This is because metal objects such as watches and jewelry can be hazardous during an MRI scan due to the strong magnetic field, leading to potential movement or heating of the metal objects, causing harm to the client.
A: The client lies still - This is important for obtaining clear images during an MRI scan and does not pose a threat to the client.
C: The client asks questions - Asking questions during an MRI scan does not pose a direct threat to the client's safety.
D: The client hears thumping sounds - Thumping sounds are a normal part of the MRI scan and do not pose a threat to the client's safety.
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An adult has a central venous line. Which of the following should the nurse include in the plan of care?
- A. Complete blood count and electrolytes
- B. Regular chest x rays to ensure proper placement of the central line
- C. Continuous infusion of the solution at a keep vein open rate
- D. Any signs of infection, air embolus, and leakage or puncture
Correct Answer: D
Rationale: The correct answer is D because monitoring for signs of infection, air embolus, and leakage/puncture are crucial in caring for a patient with a central venous line to prevent serious complications. Infections can lead to sepsis, air embolus can cause respiratory distress, and leakage/puncture can result in hemorrhage or damage to surrounding tissues.
A: While a complete blood count and electrolytes may be important for monitoring the patient's overall health, they are not specific to the central venous line care.
B: Regular chest x-rays are not necessary unless there are specific indications of line malposition or complications.
C: Continuous infusion at a keep-vein-open rate is a standard practice but does not address the critical aspects of central line care mentioned in option D.
Therefore, monitoring for signs of infection, air embolus, and leakage/puncture is the most essential component of the plan of care for a patient with a central venous line.
Which is the most reliable method for monitoring fluid balance?
- A. Daily intake and output
- B. Vital signs
- C. Daily weight
- D. Skin turgor
Correct Answer: A
Rationale: The correct answer is A: Daily intake and output. Monitoring fluid balance involves tracking the amount of fluids taken in and expelled from the body. Intake includes oral, IV, and tube feedings, while output includes urine, vomitus, diarrhea, and any other fluid losses. Daily intake and output provide a comprehensive view of a patient's fluid status, helping identify trends and potential issues. Vital signs (B) provide general information but not specific to fluid balance. Daily weight (C) can fluctuate due to various factors, not just fluid status. Skin turgor (D) is a late sign of dehydration and not as reliable as intake and output monitoring.
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
- A. Posttrauma syndrome
- B. Constipation
- C. Acute pain
- D. Anxiety
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for the patient with a right femur fracture stabilized in a full leg cast is "Acute pain" (Choice C). The rationale for this is as follows:
1. The patient is experiencing moderate discomfort due to the fracture and immobilization in the cast, indicating a need for pain management.
2. Acute pain is a priority in this situation as it can impact the patient's comfort, mobility, and overall recovery.
3. Managing pain effectively is crucial for promoting healing, preventing complications, and improving the patient's quality of life.
4. Posttrauma syndrome (Choice A) may be a consideration in the long term but is not the immediate priority. Constipation (Choice B) is not the most pertinent nursing diagnosis in this scenario. Anxiety (Choice D) may be present but addressing pain is more urgent and directly related to the patient's current condition.
A client with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
- A. Vision changes
- B. Headache
- C. Hearing loss
- D. Anorexia
Correct Answer: A
Rationale: The correct answer is A: Vision changes. This is crucial to report immediately because tamoxifen can cause serious eye problems such as retinopathy. Vision changes could indicate a potentially serious adverse reaction that requires prompt medical attention to prevent permanent damage. Headache, hearing loss, and anorexia are not typically associated with tamoxifen use and are less urgent in nature. Reporting vision changes promptly can help prevent irreversible harm and ensure timely intervention.
As the surgical incision is closed, who are the personnel in-charge in counting the needles, sponges, and instruments?
- A. the surgeon and anesthesiologist
- B. the surgeon and the registered
- C. the circulating and scrub nurse nurse first assistant
- D. the anesthesiologist and anesthetist
Correct Answer: C
Rationale: The correct answer is C - the circulating and scrub nurse first assistant. The circulating nurse is responsible for counting needles, sponges, and instruments during the closing of the surgical incision to ensure nothing is left inside the patient. The scrub nurse first assistant also plays a crucial role in this process by assisting in the counting and keeping track of the items used during the procedure. The other choices are incorrect because the surgeon and anesthesiologist (A) are not typically involved in counting items during the surgical closure, the surgeon and the registered (B) may not have the necessary training for accurate counting, and the anesthesiologist and anesthetist (D) are not directly involved in the surgical closing process.