Nokea
When preparing a client for magnetic resonance imaging, the nurse should implement which of the following?
- A. Obtain informed consent and administer atropine 0.4 mg
- B. Scrub the injection site for 15 minutes
- C. Remove any jewelry and inquire about metal implants
- D. Administer Benadryl 50 mg/mL IV
Correct Answer: C
Rationale: MRI safety requires removing jewelry and screening for metal implants to prevent injury from magnetic fields. The other actions are unnecessary or incorrect.
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A 13-year-old female has been diagnosed with celiac disease. Which of the following dinner trays would be acceptable?
- A. baked chicken breast, carrots, baked potato with cheese
- B. turkey and cheese sandwich on wheat bread, cabbage slaw, apple slices
- C. spaghetti with meatballs, Caesar salad, banana
- D. pulled pork on flour tortillas, wild rice, black beans
Correct Answer: A
Rationale: Celiac disease requires a gluten-free diet. Option A (chicken, carrots, potato) is gluten-free, while others contain gluten (wheat bread, spaghetti, flour tortillas).
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
- A. Using oil- or cream-based soaps
- B. Flossing between the teeth
- C. The intake of salt
- D. Using an electric razor
Correct Answer: B
Rationale: Flossing can cause gum bleeding, increasing infection and bleeding risks in leukemia clients with low platelet counts.
The nurse has inserted a nasogastric tube and aspirated gastric contents to check the pH with color-coded pH paper. The aspirate is dark brown, and pH measures slightly less than 5 according to the color chart. What does this pH usually indicate?
- A. Gastric aspirate
- B. Intestinal aspirate
- C. Respiratory aspirate
- D. Inconclusive results
Correct Answer: A
Rationale: A pH < 5 with dark brown aspirate indicates gastric placement (A). Intestinal aspirate (B) has pH > 6, respiratory (C) is > 7, and results are conclusive (D).
A client has suffered a severe electrical burn. Which medication would the nurse expect to have ordered for application to the burned area?
- A. Mafenide acetate (Sulfamylon)
- B. Silver nitrate
- C. Providone-iodine ointment
- D. Silver sulfadiazine (Silvadene)
Correct Answer: D
Rationale: Silver sulfadiazine (Silvadene) is commonly used for electrical burns due to its broad-spectrum antimicrobial properties and soothing effect on burn wounds.
A client is receiving end-of-life care and tells the nurse that he has not always lived the way he should have or treated his children well. Which of the following responses is the most appropriate?
- A. What kinds of things have you done?'
- B. There are things that you regret.'
- C. I'm sure those things don't matter anymore.'
- D. It's not too late to ask for forgiveness.'
Correct Answer: B
Rationale: Reflecting that the client has regrets (B) is empathetic and opens further discussion without judgment. Asking for details (A), dismissing concerns (C), or suggesting forgiveness (D) may not be appropriate.