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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Pressing on the skin barrier for about 30 seconds ensures that it adheres properly to the skin, which helps secure the ostomy appliance and prevents leakage.
Choice B Reason:
Moisturizing soap is not recommended for cleaning around the stoma, as it can leave a residue that interferes with the appliance's adhesion. Mild soap without moisturizers or just water should be used.
Choice C Reason:
Applying talc powder around the stoma can prevent the appliance from adhering properly, leading to leakage. It is not recommended for ostomy care.
Choice D Reason:
The skin barrier should be cut to fit closely around the stoma, leaving no more than a 1/8 inch gap, not 1/2 inch. A larger opening may cause skin irritation or leakage.
Correct Answer is C
Explanation
Choice A Reason:
"Opioids will be restricted if your partner develops respiratory distress." This statement might cause unnecessary concern or confusion. While opioid use might be adjusted based on the client's condition and symptoms, framing it in terms of restriction might not be the most appropriate way to communicate about pain management in end-of-life care.
Choice B Reason:
"Encourage your partner to eat three large meals each day." Encouraging large meals might not align with the typical dietary approach for someone in end-of-life care, especially if they have reduced appetite or are unable to eat comfortably. End-of-life care often focuses on providing smaller, more manageable meals based on the individual's preferences and capabilities.
Choice C Reason:
"Assume your partner can hear you, even if they do not respond. “This statement encourages the partner to communicate with their loved one, acknowledging the potential for the person to hear even if they are not responsive. Many studies suggest that hearing may persist even in individuals who are unresponsive or in a comatose state, so speaking to them can provide comfort and connection.
Choice D Reason:
"We will use an electric blanket to keep your partner warm." The use of an electric blanket might not be suitable, as the client's sensitivity to temperature might change in end-of-life care. Other methods, such as blankets or adjusting the room temperature, could be more appropriate to ensure comfort without the risks associated with electric blankets.
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