A nurse is caring for a client who is scheduled for a CT scan that requires contrast dye. Which of the following actions is the priority for the nurse to take?

Question the client about allergies before the procedure.

Tell the client to increase fluid intake following the procedure.

Evaluate the client for claustrophobia.

Inform the client about the steps of the procedure.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Questioning the client about allergies before the procedure is appropriate. It is crucial to assess the client for any allergies, especially to contrast dye, before the procedure. Allergic reactions to contrast dye can range from mild to severe, and prompt identification of potential allergies is essential to prevent adverse reactions. If the client has a known allergy to the contrast dye, alternative imaging methods or pre-medication may be considered.

Choice B Reason:

Telling the client to increase fluid intake following the procedure is inappropriate. This instruction is relevant post-procedure for the elimination of the contrast dye from the body. However, it is not the priority at this moment, and the client's safety during the procedure takes precedence.

Choice C Reason:

Evaluating the client for claustrophobia is appropriate. Assessing for claustrophobia is important, especially if the CT scan involves an enclosed space. However, this assessment can typically be conducted in advance of the procedure during the pre-procedure preparations.

Choice D Reason:

Informing the client about the steps of the procedure is inappropriate. Providing information about the procedure is important for the client's understanding and cooperation. However, ensuring the client's safety during the procedure by assessing for potential allergies to the contrast dye comes first.

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Correct Answer is C

Explanation

Choice A Reason:

Turning the hearing aid off for 5 minutes is inappropriate action. Turning the hearing aid off may temporarily stop the whistling sound, but it doesn't address the underlying issue. Additionally, it would leave the client without the ability to hear during that time.

Choice B Reason:

Cleaning the hearing aid with isopropyl alcohol is inappropriate action. While cleaning the hearing aid is important for maintenance, using isopropyl alcohol may not directly address the issue of whistling. It's a good practice for routine cleaning, but it may not be the solution in this specific case.

Choice C Reason:

Decreasing the volume on the hearing aid is appropriate action. Whistling sounds, also known as feedback, can occur when the volume on the hearing aid is too high. Decreasing the volume is a reasonable first step to address this issue.

Choice D Reason:

Soaking the hearing aid in warm water is inappropriate. Soaking a hearing aid in warm water is not recommended, as moisture can damage the internal components of the hearing aid. It's essential to keep hearing aids dry to ensure proper functioning.

A. Check a client's peripheral IV site for redness or swelling. B. Measure the intake and output of a client who has received furosemide. C. Reinforce teaching with a client about crutch-gait walking. D. Assess the pain level of a client who has received acetaminophen.

Correct Answer is B

Explanation

A. Check a client's peripheral IV site for redness or swelling.
This task involves assessing the client's IV site for signs of complications. While it requires observation and reporting, it may involve some interpretation and judgment. This task is better suited for a licensed nurse.

B. Measure the intake and output of a client who has received furosemide.
Measuring intake and output is a routine task that involves quantifying the fluids a client consumes and eliminates. This is a task that can be appropriately delegated to an assistive personnel (AP) under the supervision and direction of the nurse.

C. Reinforce teaching with a client about crutch-gait walking.
Teaching requires a level of education, explanation, and clarification that goes beyond routine tasks. This is typically a nursing responsibility and should not be delegated to an AP.

D. Assess the pain level of a client who has received acetaminophen.
Pain assessment involves subjective information, and determining the appropriate response may require clinical judgment. This task is better suited for a licensed nurse.

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A nurse is caring for a client who is scheduled for a CT scan that requires contrast dye. Which of the following actions is the priority for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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