The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam?
-
Solution
Answer B is correct. The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity. The client will be positioned sitting up or leaning over a table, making answer A incorrect. The client is usually awake during the procedure, and medications are not commonly inserted into the peritoneal cavity during this procedure; thus, answers C and D are incorrect (although this could depend on the circumstances).
The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?
-
Solution
Answer A is correct. Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic crises. Furosemide (answer B) is a diuretic, Prostigmin (answer C) is the treatment for myasthenia gravis, and Promethazine (answer D) is an antiemetic, antianxiety medication. Thus, answers B, C, and D are incorrect.
The first exercise that should be performed by the client who had a mastectomy is:
-
Solution
Answer D is correct. The first exercise that should be done by the client with a mastectomy is squeezing the ball. Answers A, B, and C are incorrect as the first step; they are implemented later.
The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?
-
Solution
Answer D is correct. The mothers in answers A, B, and C all require RhoGam and, thus, are incorrect. The mother in answer D is the only one who does not require a injection.
Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction?
-
Solution
Answer A is correct. Answer A, AST, is not specific for myocardial infarction. Troponin, CK-MB, and myoglobin, in answers B, C, and D, are more specific, although myoglobin is also elevated in burns and trauma to muscles.
The client with a myocardial infarction comes to the nurse’s station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?
-
Solution
Answer B is correct. The client who says he has nothing wrong is in denial about his myocardial infarction. Rationalization is making excuses for what happened, projection is projecting feeling or thoughts onto others, and conversion reaction is converting a psychological trauma into a physical illness; thus, answers A, C, and D are incorrect.
The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN?
-
Solution
Answer C is correct. When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. Answers A, B, and D are not directly related to the question and are incorrect.
The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge?
-
Solution
Answer B is correct. A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers A, C, and D will not prevent the client from being able to care for himself and, thus, are incorrect.
The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:
-
Solution
Answer C is correct. Lactulose is administered to the client with cirrhosis to lower ammonia levels. Answers A, B, and D are incorrect because this does not have an effect on the other lab values.
The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:
-
Solution
Answer B is correct. If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer A, as not enough; straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not urine at all. However, the physician might order a white blood cell count.