Nokea
A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
- A. Aspiration noted on honey thick diet.
- B. Pain with a bowel movement
- C. Pain felt in the left upper quadrant
- D. Right shoulder pain
Correct Answer: B
Rationale: Bowel movement pain should be examined with a colonoscopy not an endoscopy.
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A client receiving tetracycline.
The nurse should include which of the following in a teaching plan for a client receiving tetracycline?
- A. Take the medication with milk or antacids to decrease GI problems.
- B. The medication should always be taken with meals.
- C. Use a maximum-protection sunscreen when outdoors.
- D. Crackers and juice will help decrease gastric irritation.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) tetracycline should never be taken with milk or antacids as these inhibit the medication's action (2) should take with full glass of water at least one hour before or two hours after meals (3) correct-because of problems related to photosensitivity, sunscreen, wide-brimmed hats, and long sleeves should be worn when client is at risk for sun exposure (4) should take with full glass of water at least one hour before or two hours after meals
The nurse is caring for a client with a suspected pulmonary embolism.
- A. Which diagnostic Test should the nurse anticipate for a client with a suspected pulmonary embolism?
- B. Chest X-ray.
- C. D-dimer blood Test .
- D. Electrocardiogram (ECG).
- E. Arterial blood gas (ABG).
Correct Answer: B
Rationale: A D-dimer blood Test is a sensitive screening tool for pulmonary embolism, detecting fibrin degradation products from a clot. Chest X-ray and ECG are non-specific, and ABG assesses oxygenation but not the diagnosis directly.
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Calcium level of 8.0 mg/dL.
- B. Temperature of 99.5°F (37.5°C).
- C. Heart rate of 100 bpm.
- D. Pain at the incision site.
Correct Answer: A
Rationale: A calcium level of 8.0 mg/dL indicates hypocalcemia, a serious complication post-thyroidectomy due to parathyroid damage, risking tetany or seizures. Options B, C, and D are expected: slight fever, tachycardia, and incision pain are common postoperatively.
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following actions is the PRIORITY?
- A. Monitor the client for neck swelling.
- B. Administer pain medication as needed.
- C. Encourage the client to cough and deep breathe.
- D. Check the incision for drainage.
Correct Answer: A
Rationale: Monitoring for neck swelling is the priority to detect hematoma, a life-threatening complication post-thyroidectomy that can cause airway obstruction. Options B, C, and D are important but secondary: pain management, respiratory exercises, and incision checks follow airway safety.
The nurse is planning care for a client with a diagnosis of paranoid schizophrenia. The nurse knows that questioning the client about his false ideas will
- A. cause him to defend the idea.
- B. help him clarify his thoughts.
- C. facilitate better communication.
- D. lead to a breakdown of the defense.
Correct Answer: A
Rationale: contraindicated; encourages patient to engage in further distortion of reality