Nokea
The nurse teaches a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client has a need for further teaching if the client makes which statement?
- A. An anesthetic throat spray will be used.
- B. A signed informed consent is necessary.
- C. Medication will be given orally for sedation.
- D. It is important to lie still during the procedure.
Correct Answer: C
Rationale: Intravenous sedation (not oral) is given to relax the client, and an anesthetic throat spray is used to help keep the client from gagging as the endoscope is passed. The client has to sign an informed consent form. The client also needs to lie still for ERCP, which takes about an hour to perform.
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The sudden onset of which of the following indicates a potentially serious complication for the client receiving an I.V. infusion?
- A. Noisy respirations.
- B. Pupillary constriction.
- C. Halitosis.
- D. Moist skin.
Correct Answer: A
Rationale: Noisy respirations may indicate fluid overload or pulmonary edema, a serious I.V. infusion complication requiring immediate intervention.
The nurse is caring for a client with a spinal cord injury at C5. Which complication should the nurse monitor for?
- A. Respiratory distress
- B. Urinary retention
- C. Pressure ulcers
- D. All of the above
Correct Answer: D
Rationale: A C5 spinal cord injury can cause respiratory distress (diaphragm impairment), urinary retention (loss of bladder control), and pressure ulcers (immobility), requiring comprehensive monitoring.
The nurse is caring for a client with a diagnosis of peptic ulcer disease. When monitoring the client for possible gastrointestinal perforation, the nurse identifies the importance of what assessment data?
- A. Slow, strong pulses
- B. Increase in bowel sounds
- C. Positive guaiac stool tests
- D. Sudden, severe abdominal pain
Correct Answer: D
Rationale: Sudden, severe abdominal pain is a sign of perforation. When perforation occurs, the pulse will more likely be weak and rapid. The nurse may be unable to hear bowel sounds at all. Positive guaiac stool results indicate the presence of bleeding but are not necessarily indicative of perforation.
You are serving as the supervisory nurse for a home healthcare agency in the community. You are doing an admission assessment for a 76 year old male client who resides with his elderly wife. Which of the following assessments would indicate that the couple needs some education relating to home safety?
- A. The client has refrigerated foods labelled with an expiration date.
- B. You assess that the home is free of scatter rugs that many use to protect the feet against hard floors.
- C. The client uses the FIFO method for insuring food safety.
- D. The client assures you that the smoke alarm batteries are replaced annually to insure that they work.
Correct Answer: B
Rationale: The absence of scatter rugs is a safety feature, not a concern requiring education. Labeled foods , FIFO method , and annual smoke alarm battery replacement are all safe practices. However, the question implies a need for education, and B is the least directly related to a safety deficit, but no clear safety issue is present in the options provided.
The nurse is caring for a client with a history of burns covering 30% of the body. Which of the following interventions should be prioritized?
- A. Administer I.V. fluids.
- B. Apply antibiotic cream.
- C. Monitor for infection.
- D. Administer analgesics.
Correct Answer: A
Rationale: I.V. fluids are the priority to replace fluid loss and prevent hypovolemic shock in burn injuries.