The nurse recognizes the need for client education when the client scheduled for a computed tomography (CT) states:

"I will be drinking a lot of fluid after the test is over."

"I will be anesthetized so that I lie perfectly still during the procedure."

"I will make sure I let them know I do not have a shellfish ally."

"will follow the food and drink restrictions as directed before the test is scheduled."

Answer and Explanation

The Correct Answer is B

A.   This statement suggests that the client may not understand the purpose or procedure of the CT scan. CT scans typically do not require the client to drink excessive fluids afterward. However, hydration might be encouraged if contrast dye was used to help eliminate it from the body. Education is needed to clarify post-procedure instructions.
B.   This statement indicates a misconception about the procedure. CT scans do not usually require anesthesia unless it's a complex situation, such as a young child or someone with severe claustrophobia. It's essential to educate the client about what to expect during the CT scan to reduce anxiety and ensure cooperation during the procedure.
C.   This statement shows awareness of potential allergies to contrast dye, which often contains iodine. It indicates that the client understands the importance of disclosing allergies to the healthcare team before the procedure. While this is generally a positive sign of awareness, further education may still be needed to ensure complete understanding of allergy management.
D.   This statement demonstrates understanding of pre-procedure instructions, which often include fasting or specific dietary restrictions. It suggests that the client understands the importance of these restrictions to ensure accurate test results and safety during the CT scan.

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Correct Answer is B

Explanation

A. Deferasirox is a medication used to treat chronic iron overload due to blood transfusions. It is not used as an antidote for heparin.
B. Protamine sulfate is the antidote for heparin. It works by binding to heparin, neutralizing its anticoagulant effects. Protamine sulfate is typically used in cases of heparin overdose or when rapid reversal of heparin's effects is necessary, such as during surgery or if there is active bleeding.
C. Acetylcysteine is used as an antidote for acetaminophen (paracetamol) overdose due to its ability to replenish glutathione stores in the liver and protect against liver damage. It has no role in reversing heparin's effects.
D. Vitamin K is the antidote for warfarin, not heparin. It promotes the synthesis of clotting factors in the liver that are inhibited by warfarin, thus reversing its anticoagulant effects.

A. Complete an incident report. B. Take the specimen to the laboratory. C. Report the AP to the charge nurse. D. Ask the AP about her concerns with the assignment.

Correct Answer is D

Explanation

A. Completing an incident report may be necessary if the refusal could potentially impact patient care or if there are policies or procedures in place that require documenting such incidents. It helps to document the details of the refusal and any subsequent actions taken.
B. If the AP refuses to take the specimen, the nurse may need to take responsibility for ensuring the specimen is delivered to the laboratory promptly. This ensures that patient care activities are not delayed and that necessary diagnostic tests are performed in a timely manner.
C. Reporting the refusal to the charge nurse or supervisor is appropriate, especially if there are concerns about the AP's behavior or if it is part of the facility's policy to escalate such incidents. The charge nurse can then address the situation and determine the appropriate course of action.

D. Communicating with the AP to understand their concerns is essential. It allows the nurse to clarify any misunderstandings, address any issues or barriers the AP may have, and potentially resolve the situation collaboratively. It's important to listen to the AP's perspective and provide clarification or reassurance if needed.

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The nurse recognizes the need for client education when the client scheduled for a computed tomography (CT) states:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects?

Correct Answer is B

Explanation

A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid- base imbalances?

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A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.1, PaCO2 70 mm Hg, and HCO3 22 mEq/L. Which intervention does the nurse implement first?

A client returns to the unit after having a bronchoscopy. The client states "my throat is so dry. Can I have a glass of water?". How will the nurse respond?

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?

A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis?