Nokea
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
- A. Red-tinged drainage on the dressing
- B. Cloudy urine in the catheter
- C. Clear drainage on the dressings
- D. Mild back pain at the surgical site
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice D) is common after this surgery and does not necessarily indicate a complication.
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A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?
- A. Encouraging a client to take pain medication despite refusal.
- B. Referring a client who has COPD for palliative care services.
- C. Discharging a client early to free up hospital beds.
- D. Withholding information about a new diagnosis to prevent distress.
Correct Answer: B
Rationale: The correct answer is B because referring a client with COPD for palliative care services demonstrates advocating for the client's best interest, ensuring they receive appropriate care to manage symptoms and improve quality of life. This action aligns with the nurse's role as a client advocate by advocating for the client's autonomy and well-being. In contrast, choices A, C, and D do not prioritize the client's best interests or rights. Choice A disregards the client's autonomy by encouraging medication against their wishes. Choice C prioritizes hospital efficiency over the client's needs. Choice D violates the client's right to informed decision-making by withholding essential information. Overall, choice B best exemplifies client advocacy in nursing practice.
A nurse is assessing a client who has hypocalcemia. In which of the following areas should the nurse tap on the clients face to detect the presence of Chvosteks sign?
- A. Cheek just in front of the ear
- B. Supraorbital ridge
- C. Jaw and mastoid muscle
Correct Answer: A
Rationale: The correct answer is A: Cheek just in front of the ear. Chvostek's sign is a facial spasm elicited by tapping the facial nerve in front of the ear. This sign is indicative of hypocalcemia, as low calcium levels can lead to increased nerve excitability. Tapping on the cheek in this specific area allows the nurse to assess for this sign. Choices B, C, D, E, F, and G are incorrect as they do not target the specific facial nerve area where Chvostek's sign can be elicited. It's important for the nurse to be precise in assessing for this sign to accurately diagnose and manage the client's hypocalcemia.
A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the following quadrants should the nurse anticipate the client to be experiencing abdominal pain?
- A. Right lower quadrant
- B. Left lower quadrant
- C. Upper left quadrant
- D. Mid-epigastric area
Correct Answer: B
Rationale: The correct answer is B: Left lower quadrant. Diverticular disease commonly causes pain in the left lower quadrant due to inflammation or infection of the diverticula, small pouches that can develop in the colon wall. This area corresponds to the location of the descending and sigmoid colon, where most diverticula occur. Pain in the right lower quadrant (choice A) is more indicative of appendicitis. Upper left quadrant pain (choice C) is more likely related to conditions involving the spleen or stomach. Mid-epigastric pain (choice D) is typically associated with issues related to the stomach or pancreas.
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
- A. Peripheral neuropathy
- B. Hypertension
- C. Retinopathy
- D. Stroke
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes mellitus, microvascular complications involve damage to small blood vessels. Retinopathy specifically affects the blood vessels in the retina, leading to vision problems. Peripheral neuropathy (A) is a macrovascular complication affecting nerves. Hypertension (B) is a common comorbidity in diabetes but not a direct microvascular complication. Stroke (D) is a macrovascular complication involving larger blood vessels in the brain. Therefore, the presence of retinopathy is a clear indication of a microvascular complication in a client with type 2 diabetes mellitus.
A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the clients risk of developing breast cancer?
- A. Daily caffeine consumption
- B. A history of seasonal allergies
- C. Oral contraceptives were taken for the last 6 years
- D. Routine use of multivitamins
Correct Answer: C
Rationale: The correct answer is C: Oral contraceptives were taken for the last 6 years. Long-term use of oral contraceptives has been associated with a slightly increased risk of developing breast cancer. Estrogen and progesterone in oral contraceptives can stimulate the growth of breast tissue, potentially leading to cancer over time. Daily caffeine consumption (choice A) and a history of seasonal allergies (choice B) do not have a direct correlation with an increased risk of breast cancer. Routine use of multivitamins (choice D) is generally not linked to an increased risk of breast cancer.