Question 1:
A nurse is caring for a client who is hemorrhaging and hypotensive from
esophageal variceal bleeding. Which of the following actions should
... [Show More] the nurse
take first?
A. Administer vasopressin to the client.
B. Request blood from blood bank.
C. Verify that the client has adequate IV access.
D. Insert an indwelling urinary catheter.
Show correct answer and explanation
Explanation
Verify that the client has adequate IV access.
Choice A rationale:
Administering vasopressin to the client might be necessary to manage the
hemorrhage, but before any medication administration, it is crucial to ensure
the client has adequate IV access. Vasopressin is a vasoconstrictor and can
help control bleeding from esophageal varices, but its effectiveness relies on IV
access to deliver the medication promptly.
Choice B rationale:
Requesting blood from the blood bank is essential for a client experiencing
significant bleeding. However, the priority action is to verify IV access to
administer any necessary blood products.
Choice C rationale:
This is the correct choice. Before initiating any interventions, ensuring the
client has appropriate IV access is a priority. Adequate IV access is necessary
to administer fluids, medications, or blood products promptly and effectively
stabilize the client's blood pressure.
Choice D rationale:
Inserting an indwelling urinary catheter is not the priority action in this
situation. While monitoring urine output is important, it should be secondary to
addressing the client's hypotension and hemorrhage.
Question 2:
A nurse is providing teaching about dietary options for a client who has
cholelithiasis. Which of the following statements should the nurse include in
the teaching?
A. "Cauliflower is a good dietary choice.".
B. "Increase the amount of egg yolks in your diet.".
C. "Select desserts such as angel-food cake.".
D. "Eat choice or prime cuts of meat.".
Show correct answer and explanation
Explanation
Choice A rationale:
Cauliflower is not a good dietary choice for a client with cholelithiasis.
Cholelithiasis refers to the presence of gallstones, and certain foods, including
cauliflower, can exacerbate symptoms in some individuals.
Choice B rationale:
Increasing the amount of egg yolks in the diet is not advisable for a client with
cholelithiasis. Egg yolks are high in cholesterol and can contribute to gallstone
formation.
Choice C rationale:
This is the correct choice. Desserts like angel-food cake are a better dietary
option for a client with cholelithiasis. Angel-food cake is typically low in fat and
cholesterol, making it a more suitable choice for those with gallbladder issues.
Choice D rationale:
Eating choice or prime cuts of meat is not recommended for clients with
cholelithiasis. These types of meat are often higher in fat, which can trigger
gallbladder symptoms.
Question 3:
A nurse is planning care for a client who is receiving brachytherapy. Which of
the following interventions should the nurse include in the plan of care?
A. Dispose of the client's feces and urine in a special container.
B. Instruct visitors to limit the visit to 60 min each day.
C. Keep the client's linens in the room until after removal of the radiation source.
D. Keep one dosimeter badge available for the staff to share while caring for the
client.
Show correct answer and explanation
Explanation
Dispose of the client's feces and urine in a special container.
Choice A rationale:
This is the correct choice. Brachytherapy involves the placement of a radiation
source in or near the tumor. To minimize radiation exposure to others, the client's
bodily fluids (feces and urine) should be considered radioactive and disposed of
properly in a designated container.
Choice B rationale:
While limiting the time of visitors can be a good measure to reduce radiation
exposure, it is not the priority intervention. The primary concern is proper handling
and disposal of radioactive bodily fluids. [Show Less]