Nokea
A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:
- A. Reinforce the dressing.
- B. Continue to monitor the dressing.
- C. Notify the physician.
- D. Note the time and amount of blood.
Correct Answer: C
Rationale: The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. Blood on the dressing is unusual and requires prompt action to assess and manage potential complications.
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A client with a history of a thyroidectomy is receiving Calcitonin (Miacalcin). The nurse should monitor the client for:
- A. Hypocalcemia
- B. Hyperglycemia
- C. Hypotension
- D. Weight gain
Correct Answer: A
Rationale: Calcitonin lowers serum calcium, risking hypocalcemia, requiring monitoring for symptoms like tingling. Hyperglycemia, hypotension, and weight gain are not primary concerns.
The client is admitted with a diagnosis of vasa previa. Which delivery method is most likely to be planned?
- A. Vaginal delivery
- B. Cesarean section
- C. Forceps-assisted delivery
- D. Vacuum-assisted delivery
Correct Answer: B
Rationale: Vasa previa with fetal vessels crossing the cervical os requires cesarean section to prevent vessel rupture and fetal exsanguination during vaginal delivery. Forceps or vacuum delivery increases risk.
Which of the following findings would be expected in the infant with biliary atresia?
- A. Rapid weight gain and hepatomegaly
- B. Dark stools and poor weight gain
- C. Abdominal distention and poor weight gain
- D. Abdominal distention and rapid weight gain
Correct Answer: C
Rationale: Biliary atresia causes bile flow obstruction, leading to abdominal distention (from hepatomegaly) and poor weight gain due to malabsorption. Stools are pale, not dark, and weight gain is not rapid.
A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:
- A. Demand that she relax
- B. Ask what is the problem
- C. Stand or sit next to her
- D. Give her something to do
Correct Answer: C
Rationale: Standing or sitting next to the client conveys caring and provides a sense of security, reducing anxiety.
A client with a history of a kidney stone is being discharged. The nurse should teach the client to:
- A. Increase fluid intake
- B. Avoid dairy products
- C. Limit protein intake
- D. Take vitamin C supplements
Correct Answer: A
Rationale: Increasing fluid intake prevents kidney stone recurrence by diluting urine and flushing crystals. Dairy, protein, and vitamin C restrictions depend on stone type but are secondary.