Nokea
A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is to:
- A. Check the blood pressure
- B. Monitor the temperature
- C. Evaluate the urinary output
- D. Check the specific gravity of the urine
Correct Answer: A
Rationale: Blood pressure monitoring is critical post-adrenalectomy, as the adrenal gland regulates blood pressure through hormone production, and surgery may cause instability.
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The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:
- A. You may be electrocuted if you use water with this unit.'
- B. Please report skin irritation to the doctor.'
- C. The unit may be used anywhere on the body without fear of adverse reactions.'
- D. A cream should be applied to the skin before applying the unit.'
Correct Answer: B
Rationale: Skin irritation is a common side effect of TENS; reporting it ensures timely management.
Lochia serosa usually is evident on days 4 to 10 postpartum. When teaching the client about postpartum care, how should the nurse describe lochia serosa?
- A. Dark red discharge with small clots
- B. Yellowish discharge
- C. Pinkish to brownish discharge
- D. Clear watery discharge
Correct Answer: C
Rationale: Lochia serosa, days 4-10 postpartum, is pinkish to brownish (C) due to decreased blood and increased serous fluid. Dark red (A) is lochia rubra, yellowish (B) or clear (D) are not typical.
The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for:
- A. Peaked P wave
- B. Elevated ST segment
- C. Inverted T wave
- D. Prolonged QT interval
Correct Answer: D
Rationale: Quinidine can prolong the QT interval, increasing the risk of torsades de pointes.
The nurse is calculating the Apgar score for a newborn. Findings are as follows: Heart rate: 110, Respiratory effort: good cry, Muscle tone: some flexion of extremities, Reflex irritability: grimace, Color: completely pink. What is the Apgar score for this neonate?
- A. 7
- B. 8
- C. 9
- D. 10
Correct Answer: C
Rationale: Heart rate 110 (2), good cry (2), some flexion (1), grimace (1), pink (2) = 9.
The physician has prescribed Gantrisin (sulfasoxazole) 1 g in divided doses for a client with a urinary tract infection. The nurse should administer the medication:
- A. With meals or a snack
- B. 30 minutes before meals
- C. 30 minutes after meals
- D. At bedtime
Correct Answer: A
Rationale: Gantrisin should be taken with food to reduce gastrointestinal upset, and adequate fluid intake is needed to prevent crystalluria.