Question 1:
A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal bleeding. Which of the following actions
... [Show More] should 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. [Show Less]