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Which actions should the nurse take? (Select all that apply)
- A. Anticipate client to be prepped for cardiac catheterization
- B. Assist with a continuous heparin infusion
- C. Encourage the client to ambulate
- D. Anticipate an increased dosage of metoprolol
- E. Obtain a prescription for client to be NPO
- F. Request a prescription for an antibiotic
Correct Answer: A, B, D,E
Rationale: The nurse should anticipate cardiac catheterization prep (A) to ensure client readiness. Continuous heparin infusion (B) prevents clot formation during the procedure. Increased metoprolol dosage (D) may be needed for cardiac stability. NPO status (E) is crucial to prevent complications during the procedure. Ambulation (C) may be contraindicated due to the invasive nature of the procedure. Antibiotics (F) are not routinely needed for cardiac catheterization prep.
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A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?
- A. Take the sample from the outer edge of formed stool.
- B. Wear sterile gloves when collecting the sample.
- C. Collect three samples from a single bowel movement.
- D. Discard samples that contain urine.
Correct Answer: D
Rationale: The correct answer is D: Discard samples that contain urine. This is crucial because urine can interfere with the accuracy of the fecal occult blood test results, leading to false positives. By discarding samples that contain urine, the nurse ensures the reliability of the test.
A: Taking the sample from the outer edge of formed stool is not necessary for a guaiac smear sample.
B: Wearing sterile gloves is important for infection control but not specifically for collecting a guaiac smear sample.
C: Collecting three samples from a single bowel movement is not standard practice for fecal occult blood testing and may not be necessary.
E, F, G: No further options provided.
A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin.The client has prescriptions for regular and NPH insulins. Which
of the following statements by the client indicates an understanding of the teaching?
- A. I will draw up the regular insulin into the syringe first.
- B. I will shake the NPH vial vigorously before drawing up the insulin.
- C. I will store prefilled syringes in the refrigerator with the needle pointed downward.
- D. I will insert the needle at a 15-degree angle.
Correct Answer: A
Rationale: Correct Answer: A: I will draw up the regular insulin into the syringe first.
Rationale: Drawing up regular insulin first is crucial for preventing contamination between the two insulins. Regular insulin is a clear solution and should be drawn up first to prevent any cloudiness or contamination from the NPH insulin, which is a cloudy suspension. Drawing up regular insulin first ensures accuracy in dosing and prevents mixing of the two insulins.
Incorrect Choices:
B: Shaking the NPH vial vigorously before drawing up the insulin is incorrect as it can cause bubbles and affect the accuracy of the dose.
C: Storing prefilled syringes in the refrigerator with the needle pointed downward is incorrect as it can lead to leakage or contamination.
D: Inserting the needle at a 15-degree angle is incorrect as insulin injections should be administered at a 90-degree angle for proper absorption.
A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
- A. Decreased anxiety
- B. Emesis of 250 mL
- C. Increased respiratory rate to 26/min
- D. Decreased urinary output
Correct Answer: A
Rationale: The correct answer is A: Decreased anxiety. Morphine is often used to relieve pain and anxiety in patients with acute heart failure. The nurse should expect a reduction in anxiety as a positive response to the medication. Emesis (choice B) is not a typical indication of morphine effectiveness. Increased respiratory rate (choice C) may indicate respiratory depression, a potential adverse effect of morphine. Decreased urinary output (choice D) could suggest decreased cardiac output, which is not necessarily a sign of morphine effectiveness in this case.
A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?
- A. Brush your teeth for 60 seconds twice daily.
- B. Wear your dentures only during meals.
- C. Floss your teeth gently following each meal.
- D. Rinse your mouth with hydrogen peroxide.
Correct Answer: B
Rationale: The correct answer is B: Wear your dentures only during meals. This instruction is important for a client with mucositis because wearing dentures continuously can exacerbate irritation and discomfort in the mouth. By removing dentures between meals, the client can allow the oral tissues to rest and promote healing.
Choice A is incorrect because vigorous brushing for 60 seconds can further irritate the mucositis. Choice C is incorrect as flossing can also cause trauma to the inflamed tissues. Choice D is incorrect as rinsing with hydrogen peroxide can be too harsh and may worsen the condition. It's important to provide gentle care and minimize irritation to the affected areas in mucositis.
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take?
- A. Maintain low intermittent suction.
- B. Clamp the NG tube every 2 hours.
- C. Remove the NG tube immediately.
- D. Encourage high-fiber foods.
Correct Answer: A
Rationale: The correct answer is A: Maintain low intermittent suction. This is because in a small bowel obstruction, the NG tube helps decompress the bowel by removing gastric contents and relieving pressure. Low intermittent suction helps prevent excessive suction which can cause tissue damage.
Clamping the NG tube every 2 hours (choice B) is incorrect as it will prevent the tube from effectively decompressing the bowel. Removing the NG tube immediately (choice C) is also incorrect as it is needed for decompression. Encouraging high-fiber foods (choice D) is contraindicated as they can worsen the obstruction.