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 B

Explanation

A. "My stoma size will stay the same, even after it has healed." - This statement is incorrect.

Stoma size can change during the healing process and may continue to evolve over time due to factors such as swelling, retraction, or prolapse.

B. "My stoma will drain liquid fluid continuously." - This statement is correct. In an ileostomy, the stoma typically drains liquid stool continuously due to the absence of the colon, which is responsible for absorbing water from the feces.

C. "I will change my pouch system every 2 weeks." - This statement is incorrect. The frequency of pouch changes depends on individual factors such as stoma size, type of pouching system used, and personal preference. It is essential to teach clients to change their pouch when needed, which may vary from a few days to a week or longer.

D. "I will ensure that my medications are enteric coated." - This statement is unrelated to ileostomy care. Enteric-coated medications are designed to resist dissolution in the acidic environment of the stomach and instead dissolve in the alkaline environment of the small intestine. It is not directly relevant to stoma care.

A. Varicella-zoster B. Vancomycin-resistant enterococcus (VRE) C. Pertussis D. Rotavirus

Correct Answer is C

Explanation

A. Varicella-zoster requires airborne and contact precautions due to the highly contagious nature of chickenpox (varicella) and shingles (zoster).

B. Vancomycin-resistant enterococcus (VRE) typically requires contact precautions to prevent transmission.

C. Pertussis is spread via respiratory droplets, so droplet precautions are necessary to prevent transmission.

D. Rotavirus is transmitted via the fecal-oral route and typically requires contact precautions.

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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

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