A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?

Metallic taste in mouth

Abdominal fullness

Feeling flushed and warm

Swollen lips

Answer and Explanation

The Correct Answer is D

A. A metallic taste in the mouth is a common side effect of the contrast dye used in IV urography procedures and is not typically a cause for concern.

B. Abdominal fullness may occur due to the administration of fluids during the procedure and is not usually a priority finding unless it persists or is severe.

C. Feeling flushed and warm may be a transient reaction to the contrast dye and does not typically require immediate intervention unless accompanied by other symptoms.

D. Swollen lips could indicate an allergic reaction to the contrast dye, which can progress rapidly and potentially lead to a severe reaction such as anaphylaxis. This is the priority finding requiring immediate attention.

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Correct Answer is C

Explanation

A. Dependent edema is a sign of fluid overload or right-sided heart failure but is not immediately life-threatening.
B. A pericardial friction rub is a characteristic finding of pericarditis but does not indicate imminent compromise.
C. A paradoxical pulse (pulsus paradoxus) can indicate cardiac tamponade, a life-threatening complication of pericarditis. Prompt recognition and intervention are critical.
D. Substernal chest pain is a common symptom of pericarditis and should be addressed, but it is not as immediately dangerous as signs of cardiac tamponade.

A. Apply oxygen at 3 L/min per nasal cannula. B. Review the chest x-ray report. C. Flush the catheter with sterile water. D. Obtain a peripheral blood glucose level.

Correct Answer is B

Explanation

A. Apply oxygen at 3 L/min per nasal cannula: While oxygenation is important, there is no

indication in the scenario that the client requires oxygen supplementation at this time. Checking oxygen saturation would be more relevant if there were respiratory concerns.

B. Review the chest x-ray report: This is the most appropriate action before initiating the IV

infusion to ensure proper placement of the central venous catheter and absence of complications such as pneumothorax or malposition.

C. Flush the catheter with sterile water: Flushing the catheter with sterile water is not necessary before starting the infusion, especially without confirming proper catheter placement through chest x-ray.

D. Obtain a peripheral blood glucose level: While monitoring blood glucose levels may be

important in certain clinical situations, it is not directly relevant to initiating an IV infusion of Ringer's lactate via a central venous catheter.

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A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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