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 A

Explanation

A. Placing the cane on the unaffected side helps to provide better support and balance for the client. It allows the client to shift weight away from the affected side, reducing strain and risk of falls.

B. The cane should be adjusted to the height of the wrist crease when the client stands with arms relaxed at their sides, not the iliac crest. This ensures proper posture and effective use of the cane.

C. Removing the rubber tip from the cane is unsafe as the rubber tip provides traction and prevents slipping. Without it, the cane could easily slide on smooth surfaces, increasing the risk of falls.

D. Placing the cane in the closet during naps and bedtime is not practical. The client may need to use the cane immediately upon waking, and it should be easily accessible to prevent accidents.

A. "You looked like you would be the most likely to talk back with me." B. "Let's go see what activities are going on outside." C. "Why shouldn't I talk to you? You looked lonely." D. "You're curious why I am interested in you and not the others?"

Correct Answer is D

Explanation

A. This response does not address the adolescent's underlying question and may come across as dismissive.

B. This response avoids addressing the adolescent's question and suggests changing the subject.

C. This response is somewhat confrontational and does not explore the adolescent's feelings or concerns.

D. This response acknowledges the adolescent's curiosity and opens the door for further discussion about why the nurse chose to engage with them. It invites the adolescent to explore their feelings and thoughts.

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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

A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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