Nokea
The nurse receives an order for blood cultures and sensitivity for a client. Which statement is correct concerning this test?
- A. Preliminary test results are available 36 hours to allow the organisms time to grow.
- B. Growth and identification of the organism often takes 48 to 72 hours to complete.
- C. If the client has IV antibiotics infusing, stop the infusion before drawing blood cultures.
- D. If catheter sepsis is suspected, culturing the catheter tip is more accurate for identification.
Correct Answer: B
Rationale: Blood culture results typically take 48–72 hours for organism identification. Stopping antibiotics or culturing catheter tips is not standard practice.
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The nurse is performing discharge teaching to a client who is on isoniazid (INH). Which diet selection would let the nurse know that the teaching has been ineffective?
- A. Tuna casserole
- B. Ham salad sandwich
- C. Baked potato
- D. Broiled beef roast
Correct Answer: A
Rationale: Isoniazid can interact with tyramine-rich foods like tuna, causing adverse effects (e.g., hypertension). Selecting tuna casserole indicates ineffective teaching. The other foods are safe.
The physician orders an MRI of the spine with infusion for an adult female. Which of the following findings in the client's history should the nurse report to the physician?
- A. allergy to shellfish
- B. congestive heart failure (CHF)
- C. chronic cystitis
- D. metformin administered daily
Correct Answer: A
Rationale: Shellfish allergy may indicate iodine sensitivity, a concern for MRI contrast, requiring physician evaluation to prevent allergic reactions.
The nurse is teaching a client with an orthotopic bladder replacement. The nurse should tell the client to:
- A. Place a gauze pad over the stoma
- B. Lie on her side while evacuating the pouch
- C. Bear down with each voiding
- D. Wear a well-fitting drainage bag
Correct Answer: D
Rationale: A well-fitting drainage bag is essential for managing an orthotopic bladder replacement.
The nurse is preparing a client for cervical uterine radiation implant insertion. Which will be included in the teaching plan?
- A. TV or telephone use will not be allowed while the implant is in place.
- B. A Foley catheter is usually inserted.
- C. A high-fiber diet is recommended.
- D. Excretions will be considered radioactive.
Correct Answer: B
Rationale: A Foley catheter is inserted during cervical radiation implants to keep the bladder empty, reducing radiation exposure to nearby organs. The other options are incorrect or irrelevant.
A client is prescribed heparin 2,000 units SC q8 hours. The pharmacy sends heparin 5,000 units/mL. How many mL should the nurse administer every 24 hours?
- A. 0.4 mL/day
- B. 0.8 mL/day
- C. 1.2 mL/day
- D. 1.4 mL/day
Correct Answer: C
Rationale: Dose per injection: 2,000 units ÷ 5,000 units/mL = 0.4 mL. Q8 hours = 3 doses/day. 0.4 mL × 3 = 1.2 mL/day.