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A client is postoperative following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypocalcemia?
- A. Constipation
- B. Numbness and tingling of the fingers
- C. Increased thirst
- D. Frequent urination
Correct Answer: B
Rationale: Numbness and tingling of the fingers are classic signs of hypocalcemia, a condition that may result from inadvertent damage to the parathyroid glands during a thyroidectomy. These symptoms occur due to decreased levels of calcium in the bloodstream affecting nerve function. Choices A, C, and D are not typical manifestations of hypocalcemia. Constipation is more associated with hypercalcemia, increased thirst can be seen in diabetes or dehydration, and frequent urination is a symptom more commonly linked to conditions like diabetes or urinary tract issues.
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A nurse is assessing a client who has just received an opioid medication. Which of the following findings should the nurse monitor first?
- A. Constipation.
- B. Drowsiness.
- C. Orthostatic hypotension.
- D. Respiratory depression.
Correct Answer: D
Rationale: When a client receives an opioid medication, the nurse should first monitor for respiratory depression as it is a life-threatening adverse effect associated with opioids. This can lead to inadequate ventilation and hypoxia, requiring immediate intervention. Constipation, drowsiness, and orthostatic hypotension are also common side effects of opioids but are not as immediately life-threatening as respiratory depression.
A nurse is caring for a client who is 1 day postoperative following abdominal surgery. The nurse should suspect that the client has developed an infection based on which of the following findings?
- A. Blood pressure of 110/70 mm Hg
- B. Temperature of 38.5°C (101.3°F)
- C. Heart rate of 92/min
- D. Drainage at the surgical site
Correct Answer: B
Rationale: An elevated temperature of 38.5°C (101.3°F) is indicative of infection postoperatively. Fever is a common sign of infection, and temperatures above the normal range should raise suspicion. The other vital signs (blood pressure, heart rate) may be within an acceptable range, and some drainage at the surgical site can be expected postoperatively. However, the elevated temperature is a more specific indicator of a potential infection that requires immediate attention.
A healthcare provider is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following foods should the healthcare provider instruct the client to avoid?
- A. Bananas
- B. Carrots
- C. Bacon
- D. Chicken breast
Correct Answer: C
Rationale: The correct answer is C. Bacon is high in sodium, which can elevate blood pressure levels. Clients with hypertension should avoid high-sodium foods like bacon to help manage their blood pressure. Choices A, B, and D are healthier options compared to bacon and can be included in a balanced diet for someone with hypertension. Bananas are a good source of potassium, which can help in managing blood pressure. Carrots are low in sodium and high in fiber, making them a heart-healthy choice. Chicken breast is a lean protein option that is beneficial for individuals with hypertension.
A parent is being taught by a nurse how to prevent sudden infant death syndrome (SIDS). Which statement by the parent indicates an understanding of how to place the infant in the crib at bedtime?
- A. Place the infant on their stomach to sleep.
- B. Place the infant on their side to sleep.
- C. Place the infant on their back to sleep.
- D. Allow the infant to sleep with a pacifier.
Correct Answer: C
Rationale: The correct answer is C: 'Place the infant on their back to sleep.' This statement indicates an understanding of the recommended sleep position to reduce the risk of SIDS. Placing infants on their back is the safest sleep position according to guidelines to prevent SIDS. Choices A and B are incorrect as placing the infant on their stomach or side increases the risk of SIDS. While allowing the infant to sleep with a pacifier can also reduce the risk of SIDS, the most crucial step is placing the infant on their back for sleep.
A nurse is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take?
- A. Instill 500 ml of solution through the NG tube
- B. Insert a large-bore NG tube
- C. Use a cold irrigation solution
- D. Instruct the client to lie on his right side
Correct Answer: B
Rationale: The correct answer is B: 'Insert a large-bore NG tube.' When performing a gastric lavage for a client with upper gastrointestinal bleeding, a large-bore NG tube is used to effectively remove gastric contents and blood. Option A is incorrect because the amount of solution to instill depends on the specific situation and should be guided by the healthcare provider's order. Option C is incorrect because using a cold irrigation solution can lead to hypothermia and is not recommended. Option D is incorrect as there is no need to instruct the client to lie on his right side specifically for gastric lavage.