Nokea
The nurse prepares a client for a computed tomography (CT) scan of their abdomen and pelvis with intravenous (IV) contrast. The nurse should take which action before the client's exam?
- A. Remove any medicated patches before the exam
- B. Instruct the client to empty their bladder right before the test
- C. Educate the client that they may experience a flushing sensation during the exam
- D. Assess the client for an implantable pacemaker
Correct Answer: C
Rationale: Educating about the flushing sensation (C) prepares the client for the common effect of IV contrast. Patches (A) are not routinely removed, emptying the bladder (B) is not critical, and pacemakers (D) are relevant for MRI, not CT.
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A client with a peptic ulcer is prescribed sucralfate. Which statement by the client indicates an understanding of the medication?
- A. I should take sucralfate at least 1 hour before meals and at bedtime.
- B. I will avoid taking antacids completely while I'm on sucralfate.
- C. I should take sucralfate right before meals and at bedtime.
- D. I can expect immediate relief of my ulcer symptoms after taking sucralfate.
Correct Answer: A
Rationale: Sucralfate (A) should be taken 1 hour before meals and at bedtime to coat the stomach effectively. Antacids (B) can be used cautiously, and immediate relief (D) or taking it with meals (C) is incorrect.
The nurse supervises a student nurse giving medications through a nasogastric tube (NGT) to a client receiving continuous enteral feeding. Which actions by the student require follow-up by the nurse? Select all that apply.
- A. Gives each medication separately
- B. Verifies placement of the NGT prior to medication administration
- C. Elevates the head of the bed to 15 degrees
- D. Adds crushed medications directly to a tube feeding
- E. Crushes each tablet into a fine powder
Correct Answer: C,D
Rationale: Elevating the head of the bed to only 15 degrees (C) is insufficient to prevent aspiration; 30-45 degrees is recommended. Adding crushed medications to the tube feeding (D) can clog the tube or alter medication efficacy. Other actions (A, B, E) are correct.
The nurse is caring for a client with a nasogastric tube (NGT) connected to suction. Which of the following actions should the nurse perform when irrigating an NGT with water? Select all that apply.
- A. Draw up 30 mL of warm water into the syringe.
- B. Unclamp the suction tubing near the connection site to instill water.
- C. Place the tip of the syringe in the tube to gently instill warm water.
- D. Place the syringe in the blue air vent of a Salem sump or double-lumen tube.
- E. After instilling the water, hold the end of the NG tube over an irrigation tray.
- F. Observe for return of NG drainage into an available container.
Correct Answer: A,C,F
Rationale: Using 30 mL of warm water (A), gently instilling it into the tube (C), and observing for drainage return (F) ensure proper NGT irrigation without complications. Unclamping suction (B) or using the air vent (D) is incorrect, and holding the tube over a tray (E) is unnecessary.
The nurse is caring for a client who is receiving prescribed dicyclomine. Which of the following client findings would indicate a therapeutic response?
- A. Decreased abdominal cramping
- B. Absence of nausea and vomiting
- C. Decreased urinary retention
- D. Less burning with urination
Correct Answer: A
Rationale: Dicyclomine, an anticholinergic, reduces intestinal spasms, so decreased abdominal cramping indicates a therapeutic response. It is not primarily for nausea, urinary retention, or dysuria.
The nurse is assessing a client with cholecystitis. To support this finding, the nurse expects the client to localize the pain in the
- A. Right upper quadrant, radiating to the right shoulder.
- B. Right upper quadrant, radiating to the left shoulder.
- C. Right lower quadrant, radiating to the pelvic bones.
- D. Right lower quadrant, radiating to the umbilicus.
Correct Answer: A
Rationale: Cholecystitis typically causes pain in the right upper quadrant radiating to the right shoulder (A) due to gallbladder inflammation and referred pain via the phrenic nerve.