The nurse is caring for a client who is going to have an intravenous pyelogram (IVP) using a contrast medium. Which of the following assessments by the nurse are of the highest priority?
Ask whether the patient has any questions about the procedure.
Ask the patient to void before the procedure.
Check for an allergy to iodine or shellfish.
Assess the client's ability to remain still for the procedure.
The Correct Answer is C
Choice A reason: While it is important to address any questions the patient may have, it is not the highest priority before an IVP procedure.
Choice B reason: Asking the patient to void before the procedure is a standard practice, but it is not the highest priority. The bladder should be empty to allow for clear imaging, but this can be managed at the time of the procedure.
Choice C reason: Checking for an allergy to iodine or shellfish is the highest priority because the contrast medium used in an IVP can cause severe allergic reactions in patients with these allergies. This assessment must be done before administering the contrast to prevent potentially life-threatening complications.
Choice D reason: Assessing the client's ability to remain still is important for the quality of the images, but it is not as critical as ensuring the safety of the patient regarding potential allergic reactions.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Enhancing the formation of granulation tissue is not the immediate expected outcome of an escharotomy.
Choice B reason: Ensuring brisk bleeding is not the goal; minimal bleeding is expected, and it should be controlled to maintain fluid volume status.
Choice C reason: Ensuring the return of distal pulses is the expected outcome of an escharotomy, as it relieves pressure and restores circulation to the affected limbs.
Choice D reason: Decreasing edema formation is a benefit of the procedure but not the primary expected outcome.
Correct Answer is C
Explanation
Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.
Choice B reason : Educating the patient about the causes and effects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.
Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.
Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.
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