Nokea
The physician orders cholestyramine (Questran) 4 g PO qid for a 40-year-old client. The medication is provided in single-dose 4 g packets. The client asks the office nurse how to take the medication. The nurse should instruct the client to
- A. sprinkle the powder on a beverage, stir, and drink immediately.
- B. sprinkle the powder on food and eat slowly.
- C. add water to make a paste and eat, followed by 8 oz of water.
- D. sprinkle the powder on a beverage, let it stand a few minutes, and then stir and drink.
Correct Answer: D
Rationale: ensures uniform suspension
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A client is scheduled for an intravenous pyelogram (IVP).
Nursing management prior to an intravenous pyelogram (IVP) would include which of the following?
- A. A fat-free meal the evening prior to the examination and radiopaque tablets at bedtime.
- B. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter.
- C. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract.
- D. Explaining the importance of following directions regarding voiding during the Test .
Correct Answer: C
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) fat-free meal is associated with a gall bladder series (2) a retention Foley catheter may be in place, but not for the purpose of dilating the bladder sphincter (3) correct-because of the need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered (4) there are few directions the client needs to follow during the Test
A three-month-old is placed in Bryant's traction for developmental dysplasia of the hips. Which of the following toys would be appropriate for the nurse to offer the infant during hospitalization?
- A. A rattle.
- B. A stuffed animal.
- C. Colorful blocks.
- D. A tape playing nursery rhymes.
Correct Answer: A
Rationale: three-month-old can grasp a rattle
The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 for a client who has been on bedrest 48 hours in an unsuccessful attempt to arrest premature labor at 33-weeks gestation. Based on this result, the nurse would anticipate
- A. administration of ritodrine hydrochloride (Yutopar).
- B. initiation of an oxytocin (Pitocin) drip.
- C. delivery of the infant by cesarean section.
- D. continuation of bedrest until otherwise indicated.
Correct Answer: C
Rationale: because the lungs are adequately mature, there is no need to attempt to postpone labor; delivery by cesarean section is generally preferred for preterm infants
A client is admitted with a fractured right hip. The doctor writes an order for Buck's traction. Which of the following actions, if taken by the nurse, is MOST important?
- A. Turn the client every two hours to the unaffected side.
- B. Maintain the client in a supine position.
- C. Encourage the client to use a bedside commode.
- D. Placing a footboard on the bed.
Correct Answer: A
Rationale: immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side
An 8-year-old client is returned to the recovery room after a bronchoscopy.
- A. How should the nurse position an 8-year-old client after a bronchoscopy?
- B. In semi-Fowler’s position.
- C. Prone, with the head turned to the side.
- D. With the head of the bed elevated 45° and the neck extended.
- E. Supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position promotes lung expansion and reduces the risk of airway obstruction from edema or secretions post-bronchoscopy. Prone positioning limits respiratory assessment, neck extension risks airway obstruction, and supine does not optimize breathing.