Nokea
A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?
- A. Obtain a crash cart
- B. Check the calcium level
- C. Assess the dressing for drainage
- D. Assess the blood pressure for hypertension
Correct Answer: B
Rationale: Tingling around the mouth and extremities suggests hypocalcemia, a common complication post-thyroidectomy due to parathyroid gland disturbance, so checking the calcium level is the next action.
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The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:
- A. To lower the blood glucose level
- B. To lower the uric acid level
- C. To lower the ammonia level
- D. To lower the creatinine level
Correct Answer: C
Rationale: Lactulose reduces ammonia levels to prevent hepatic encephalopathy.
A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:
- A. Ask the client if he has any medication allergies
- B. Check the client's immunization record
- C. Apply a splint to immobilize the arm
- D. Administer medication for pain
Correct Answer: C
Rationale: Immobilizing the arm with a splint prevents further tissue damage and promotes healing, which is a priority after initial wound care and antibiotic administration. Checking for allergies should have been done prior to administering antibiotics, and pain management, while important, is secondary to stabilization.
A infant weighs 7 pounds at birth. The expected weight by 1 year should be:
- A. 10 pounds
- B. 12 pounds
- C. 18 pounds
- D. 21 pounds
Correct Answer: D
Rationale: Infants typically triple their birth weight by 1 year, so a 7-pound infant should weigh approximately 21 pounds.
Which assignment should not be performed by the nursing assistant?
- A. Feeding the client
- B. Bathing the client
- C. Obtaining a stool
- D. Administering a fleet enema
Correct Answer: D
Rationale: Administering an enema is an invasive procedure requiring clinical judgment, which is beyond the scope of a nursing assistant's responsibilities.
Which of the following postpartal clients is at greatest risk for hemorrhage?
- A. A gravida 1 para 1 with an uncomplicated delivery of a 7-pound infant
- B. A gravida 1 para 0 with a history of polycystic ovarian disease
- C. A gravida 3 para 3 with a history of low-birth weight infants
- D. A gravida 4 para 3 with a Caesarean section
Correct Answer: D
Rationale: A gravida 4 para 3 with a Caesarean section is at higher risk for hemorrhage due to uterine atony from multiple pregnancies and surgical delivery.