Nokea
A client is scheduled for a cholangiogram. Meglumine diatrizoate (Gastrografin) is ordered for the client.
The nurse should
- A. identify the client before administering the medication.
- B. administer the medication two hours before the procedure.
- C. administer an enema after administering the medication.
- D. instruct the client to take medication slowly with water.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-appropriate identification of client is the first nursing priority after the order is verified (five 'rights' of medication administration) (2) unnecessary (3) unnecessary (4) unnecessary
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At approximately 6 PM, the nurse begins to open the nurses' notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. The MOST appropriate nursing response is to
- A. leave approximately three or four lines for the day nurse to enter the day information and sign the chart.
- B. review with the client the activities after 1 PM, and enter what are determined to be the activities after 1 PM.
- C. begin charting on the next line below the last entry, and make a note for the day nurse to make a late entry to complete the chart.
- D. do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete charting.
Correct Answer: C
Rationale: day nurse can make a 'late entry' to add any additional information
Which of the following strategies would be MOST therapeutic as the nurse tries to analyze a bulimic client's eating habits and the circumstances that precipitate the client's eating problems?
- A. Observe family communication patterns at a 'monitored mealtime.'
- B. Distract the client at mealtime.
- C. Assign the client a food/feelings/thoughts/actions journal.
- D. Assign the client to write a 'lifeline' in relation to eating behaviors.
Correct Answer: C
Rationale: implementation, nurse is trying to analyze and understand what triggers the client's binging and purging activities, so therapeutic nursing intervention of assigning a thought/feelings/actions (T/F/A) journal relating to client's eating behaviors will be most helpful to the nurse and therapeutic to the client; after this information is gained and reviewed, collaboration by the nurse and client on other strategies such as delay and distraction techniques, stress reduction, and developing a 'lifeline' in relation to eating behaviors will further benefit the client
A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of the following changes in the pattern of urinary elimination normally occur with aging?
- A. Decreased frequency.
- B. Incontinence.
- C. Sphincter reflexes decrease.
- D. Formation of bladder stones.
Correct Answer: B
Rationale: ureters, bladder, and urethra lose muscle tone results in stress and urge incontinence
The nurse is caring for a client recently diagnosed with AIDS. Which of the following interventions by the nurse would be BEST?
- A. Inspect the skin daily for signs of breakdown.
- B. Limit the number of health care personnel caring for the patient.
- C. Utilize standard precautions when administering parenteral medications.
- D. Monitor the patient's vital signs q4h.
Correct Answer: B
Rationale: implementation, decreases exposure to microorganisms
An abdominal wound irrigation with a normal saline solution is ordered for a client. To perform this procedure, the nurse should
- A. warm the irrigating solution to 110°F (43.3°C).
- B. establish a sterile field that includes the irrigating equipment.
- C. direct the irrigating solution at the outer edges of the wound, then the center of the wound.
- D. aspirate the irrigating fluid with a syringe to prevent accumulation in the wound.
Correct Answer: B
Rationale: requires strict aseptic technique