Nokea
What must the nurse do when preparing a client for a computed tomography (CT) scan?
- A. Administer a laxative prep
- B. Encourage fluids
- C. Explain the procedure
- D. Administer a radioisotope
Correct Answer: C
Rationale: Explaining the procedure reduces anxiety and ensures cooperation. A CT scan may involve iodine dye, so checking for allergies (e.g., shellfish) is also important, but explanation is primary.
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Which client problem is the nurse’s priority concern for the client diagnosed with acute pancreatitis?
- A. Impaired nutrition.
- B. Skin integrity
- C. Anxiety
- D. Pain relief.
Correct Answer: D
Rationale: Acute pancreatitis is characterized by severe abdominal pain due to pancreatic inflammation and autodigestion. Pain relief is the priority concern, as it addresses the client’s immediate discomfort, improves patient comfort, and reduces physiological stress, which can exacerbate the condition. Using the ABCs (Airway, Breathing, Circulation) and Maslow’s hierarchy, pain is a physiological need that takes precedence. Impaired nutrition (1) is relevant but secondary, as clients are often NPO initially. Skin integrity (2) and anxiety (3) are lower priorities, as they are less immediate concerns in acute pancreatitis.
The home health nurse is admitting a client diagnosed with cancer of the pancreas. Which information is the most important for the nurse to discuss with the client?
- A. Determine the client's food preferences.
- B. Ask the client if there is an advance directive.
- C. Find out about insurance/Medicare reimbursement.
- D. Explain the client should eat as much as possible.
Correct Answer: B
Rationale: An advance directive is critical for pancreatic cancer due to poor prognosis, ensuring the client’s wishes are respected. Food preferences, insurance, and eating are secondary.
The nurse should assess for hypocalcemia based on which client statements after a subtotal thyroidectomy?
- A. I feel tingling in my hands and feet.
- B. I have a headache.
- C. I feel sleepy.
- D. I have a sore throat.
Correct Answer: A
Rationale: Tingling in the hands and feet indicates hypocalcemia, a potential complication due to parathyroid gland damage during thyroidectomy.
The nurse is preparing to care for the stable client with Addison's disease. Which skin appearance should the nurse expect when performing an assessment?
- A. Very white, dry, and scaly
- B. Bronzed and suntanned hue
- C. Diaphoretic and cyanotic
- D. Puffy and butterfly-like rash
Correct Answer: B
Rationale: The nurse should expect a bronzed, suntanned hue due to increased melanocyte-stimulating hormone in Addison's disease.
Based on the client's blood glucose measurement, the nurse immediately reevaluates the client. Which physician orders should the nurse anticipate? Select all that apply.
- A. STAT serum blood glucose
- B. Intravenous regular insulin
- C. Vital signs every 2 hours
- D. A diet of six small, frequent meals
- E. Electronic glucometer measurements before meals and at bedtime
- F. Continuous cardiac monitoring
Correct Answer: A,B,E,F
Rationale: DKA with a glucose of 498 mg/dL requires STAT serum glucose, IV insulin, frequent glucometer checks, and cardiac monitoring.