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Questions 164

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Question 1 of 5

The nurse is caring for several clients who are to have diagnostic tests. Which clients will receive similar instructions?

Correct Answer: C

Rationale: A barium enema and a colonoscopy both require a clear liquid diet and full bowel prep the day before. The only difference is that the client who is having a barium enema can have red liquids and the one who is having a colonoscopy cannot. The preparation for an upper GI series is NPO after midnight the night before. There is no preparation for a gallbladder sonogram. A gallbladder x-ray requires fat restriction the day before, taking iodine dye tablets, and NPO after midnight. The preparation for a gastroscopy is NPO after midnight the night before.

Question 2 of 5

A father brings his 17-year-old son to a walk-in clinic. The client reports a sudden severe headache. He has a temperature of 104°F and a purple rash. What is the best action for the nurse at this time?

Correct Answer: C

Rationale: Symptoms suggest meningococcal meningitis, a medical emergency requiring isolation and immediate physician notification.

Question 3 of 5

The charge nurse is reviewing events that staff nurses experienced during the shift. Which events require an incident/occurrence report to be completed? Select all that apply.

Correct Answer: B,C,D

Rationale: Assault, missed lab tests, and staff no-show are reportable incidents due to safety, care quality, and staffing issues. Brain death withdrawal follows protocol, and a visitor’s fall with refused care is less reportable.

Question 4 of 5

At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states 'My blood pressure is usually much lower.' The nurse should tell the client to

Correct Answer: A

Rationale: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is 'usually much lower,' a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

Question 5 of 5

An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions?

Correct Answer: C

Rationale: The UAP must be competent to accept the delegated task. Further assessment of the qualifications of the UAP is important in order to assign the right task.

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