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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: Asking about numbness or tingling is important to rule out neurological issues that could be causing the neck pain.

Choice B reason: While heat and cold therapy may provide relief, it is not the first action to take before assessing the cause of the pain.

Choice C reason: Providing information about exercises is helpful but should come after an initial assessment.

Choice D reason: Teaching about NSAIDs is part of pain management but should follow an assessment of symptoms and potential causes.

A. Disturbed body image B. Anxiety C. Ineﬀective protection D. Imbalanced nutrition: less than body requirements

Correct Answer is C

Explanation

Choice A reason: While disturbed body image is a concern, it is not the highest priority for a patient undergoing a bone marrow transplant.

Choice B reason: Anxiety is important to address but does not take precedence over physical health concerns in the immediate post-transplant period.

Choice C reason: Ineﬀective protection is the highest priority because patients undergoing bone marrow transplants have compromised immune systems and are at high risk for infection.

Choice D reason: Imbalanced nutrition is a concern but is secondary to the risk of infection in the immediate care of a patient post bone marrow transplant.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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