Nokea
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
- A. Wire cutters
- B. Oral airway
- C. Pliers
- D. Tracheostomy set
Correct Answer: A
Rationale: Wire cutters are essential for a fractured mandible with wiring, in case of emergency airway obstruction. Oral airway , pliers , and tracheostomy set are not standard.
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A client is admitted to the neurology unit for a myelogram.
It would be MOST important for the nurse to ask which of the following questions?
- A. Do you have any allergies?'
- B. Have you been drinking lots of fluids?'
- C. Are you wearing any metal objects?'
- D. Are you taking medication?'
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to a myelogram. (1) correct-dye is injected into subarachnoid space before an x-ray of spinal cord and vertebral column to assist in identifying spinal lesions; if client is allergic to dye, there is a major safety issue (2) important that client drink extra fluids after the Test to replace the CSF lost during Test (3) appropriate for magnetic resonance imaging (MRI) (4) obtain history of medication that can lower seizure threshold (phenothiazines, neuroleptics)
The nurse is caring for a client with a history of dementia.
- A. Which intervention is most effective for communicating with a client with dementia?
- B. Speak loudly to ensure understanding.
- C. Use simple, clear sentences.
- D. Ask open-ended questions.
- E. Provide written instructions.
Correct Answer: B
Rationale: Using simple, clear sentences enhances comprehension in dementia patients with cognitive impairment. Loud speaking is unnecessary, open-ended questions overwhelm, and written instructions are ineffective.
A 30-year-old woman is receiving levothyroxine sodium (Synthroid) 0.1 mg PO daily.
Which of the following findings would indicate to the nurse that the client is getting favorable results from the medication?
- A. Decreased blood pressure.
- B. Increased urine output.
- C. Decreased pulse rate.
- D. Increased respiratory rate.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to hypothyroidism. (1) characteristic of hypothyroidism, would indicate that medication is not working (2) correct-medication increases metabolic processes of body, including glomerular filtration, edema will decrease as water is excreted (3) characteristic of hypothyroidism, would indicate that medication is not working (4) respiratory rate may or may not be affected by medication
The nurse is caring for a client who is postoperative day 1 after a prostatectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Urinary output of 200 mL/hour.
- D. Blood-tinged urine.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-prostatectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, high urinary output, and blood-tinged urine are normal on day 1.
The nurse is caring for a client in the outpatient clinic who is four months pregnant.
- A. Which symptom reported by a four-month pregnant client requires immediate follow-up?
- B. Intermittent nausea in the morning.
- C. A white vaginal discharge.
- D. Breast tenderness bilaterally.
- E. Feeling the need to void more frequently.
Correct Answer: A
Rationale: Intermittent nausea in the second trimester (four months) is abnormal, as morning sickness typically resolves by the end of the first trimester, and may indicate complications like hyperemesis gravidarum or other issues requiring evaluation. Vaginal discharge, breast tenderness, and frequent urination are normal pregnancy symptoms.