Nokea
A 67-year-old man for an intravenous pyelogram (IVP).
The nurse prepares a 67-year-old man for an intravenous pyelogram (IVP). Which of the following information is MOST important for the nurse to obtain before the procedure?
- A. The date of the client's last EKG.
- B. The time of the client's last meal.
- C. A list of the client's allergies.
- D. A list of the medications the client takes at home.
Correct Answer: C
Rationale: Strategy: All answers are assessments. Determine why you would make the assessment and how it relates to the situation. (1) electrical activity of heart, not most important (2) should be NPO for 6-8 h, not most important (3) correct-involves injection of radiopaque dye, used to identify lesions and assess function, allergy to iodine is life-threatening (4) not most important
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A client with acute glomerulonephritis requests a snack. Which snack is suitable given the client's dietary restrictions?
- A. Orange
- B. Banana
- C. Applesauce
- D. Raisins
Correct Answer: C
Rationale: Applesauce is a suitable snack for the client with acute glomerulonephritis. Answers A, B, and D are incorrect because oranges, bananas, and dried fruits such as raisins are high in potassium, which is restricted in the diet of the client with AGN.
The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment.
- A. What should the nurse do if the patient’s left leg is externally rotated?
- B. Place a trochanter roll on the outer aspect of the thigh.
- C. Perform resistive range of motion of the left leg.
- D. Adduct and internally rotate the left leg.
- E. Instruct the patient to maintain the left leg in a neutral position.
Correct Answer: A
Rationale: A trochanter roll placed on the outer aspect of the thigh prevents external rotation by holding the hip in a neutral position and maintaining normal leg alignment. Resistive exercises, manual repositioning, or instructing the patient to maintain position are less effective, as they do not provide sustained support to prevent rotation.
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Respiratory rate of 24 breaths/min.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.
The nurse is caring for a client with a history of depression who is receiving sertraline (Zoloft) 50 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired all the time.
- B. I have trouble sleeping at night.
- C. I think about hurting myself sometimes.
- D. I have a dry mouth.
Correct Answer: C
Rationale: Thoughts of self-harm indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on sertraline. Options A, B, and D are common side effects of SSRIs (fatigue, insomnia, dry mouth) and less urgent.
The doctor writes an order for piperacillin (Pipracil) 3 g IV q6h for an adult client.
Before administering this drug, the nurse should
- A. check for known allergies to medications.
- B. ensure that the client's respiratory rate is over 12.
- C. administer dexamethasone sodium phosphate (Decadron) 2 mg IV stat.
- D. check the client's blood pressure both sitting and standing.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) correct-assessment, piperacillin (Pipracil) is a semisynthetic broad-spectrum penicillin, should not be administered to clients with known allergies (2) assessment, not relevant for administration of this medication (3) implementation, not relevant for administration of this medication (4) assessment, not relevant for administration of this medication