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Which of the following should the nurse implement to prepare a client for a kidney, ureter, bladder (KUB) radiograph test?
- A. Client must be NPO before the examination
- B. Enema to be administered prior to the examination
- C. Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
- D. No special orders are necessary for this examination
Correct Answer: D
Rationale: No special orders are necessary for this examination. No special preparation is necessary for this examination.
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The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is refusing to eat and states, 'I just don't feel good.'
- A. What is the best action for the nurse to take for a client one-day post-angioplasty who refuses to eat and feels unwell?
- B. The nurse talks with the client about how he is feeling.
- C. The nurse instructs the nursing assistant to sit with the client while he eats.
- D. The nurse contacts the physician to obtain an order for an antacid.
- E. The nurse evaluates the most recent vital signs recorded in the chart.
Correct Answer: A
Rationale: Assessment is required to determine the cause of the client’s symptoms, as they could indicate complications such as vessel closure, bleeding, hypotension, or dysrhythmias. Talking with the client to assess current symptoms is the most immediate and appropriate action. Encouraging eating, ordering medication, or reviewing past vital signs does not address the need for current assessment.
A client that has stage III pressure ulcer of the sacrum with foul smelling purulent drainage.
The nurse should intervene in which of the following situations?
- A. The LPN/LVN enters the room wearing a gown and gloves.
- B. The nursing assistant enters the room wearing a mask.
- C. The client's family brings him a milkshake.
- D. The staff lifts the client to reposition him.
Correct Answer: B
Rationale: Strategy: 'Nurse should intervene' indicates an incorrect behavior. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) contact precautions required for infected decubitus ulcer; private room if possible (2) correct-masks not needed and doors do not need to be closed (3) maintain positive nitrogen balance, should offer high protein diet with protein supplements (4) lifting prevents shearing force
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
- A. Stand on 1 foot
- B. Catch a ball
- C. Skip on alternate feet
- D. Ride a bicycle
Correct Answer: A
Rationale: Stand on 1 foot. Balancing on one foot is expected by age 3, indicating gross motor delay if absent.
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
- A. Observe for edema proximal to the site
- B. Irrigate with 5 ml of 0.9% Normal Saline
- C. Palpate for a thrill over the fistula
- D. Check color and warmth in the extremity
Correct Answer: C
Rationale: Palpate for a thrill over the fistula. A thrill indicates patency of the fistula.
A Hispanic client in the postpartum period refuses the hospital food because it is 'cold.' The best initial action by the nurse is to
- A. Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
- B. Ask the client what foods are acceptable or are unacceptable
- C. Encourage her to eat for healing and strength
- D. Schedule the dietitian to meet with the client as soon as possible
Correct Answer: B
Rationale: Ask the client what foods are acceptable or are unacceptable. Understanding cultural food preferences ensures appropriate dietary support.