Nokea
A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for:
- A. Footdrop.
- B. Knee swelling and pain.
- C. Tingling in the arm.
- D. Absence of the Achilles reflex.
Correct Answer: C
Rationale: Thoracoscopy positioning (lateral decubitus) can compress nerves in the arm, causing tingling due to brachial plexus injury. Footdrop or Achilles reflex issues are unrelated to this position.
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A client with acute renal failure has a low calcium level. The nurse should monitor for:
- A. Tetany.
- B. Hypertension.
- C. Bradycardia.
- D. Edema.
Correct Answer: A
Rationale: Low calcium can cause tetany, manifesting as muscle cramps or spasms.
A client post-amputation is experiencing depression. Which nursing action is most appropriate?
- A. Administer an antidepressant immediately.
- B. Encourage participation in a support group.
- C. Limit discussions about the amputation.
- D. Schedule a physical therapy session.
Correct Answer: B
Rationale: Encouraging participation in a support group fosters emotional coping and peer support.
The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following?
- A. Contact the client's audiologist.
- B. Cleanse the hearing aid ear mold in normal saline.
- C. Irrigate the ear canal.
- D. Check the hearing aid's placement.
Correct Answer: D
Rationale: Checking the hearing aid's placement is the first step, as improper placement or a low battery is a common cause of ineffective hearing aid function.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 5 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Click to highlight the orders that the nurse should consider a priority.
- A. Perform admission medication reconciliation and admit the client to the intensive care unit
- B. Remove the client's clothing
- C. Start a large-bore peripheral vascular access device
- D. 0.9% sodium chloride (normal saline) 1000 mL, IV, once
- E. Obtain medical records from the client's outpatient primary healthcare provider
- F. Insert temperature-sensing indwelling urinary catheter
- G. Apply a cooling blanket to the client
Correct Answer: B,C,D,F,G
Rationale: Priority orders address immediate life-threatening issues: removing clothing (B), IV access (C), saline (D), temperature catheter (F), and cooling blanket (G) manage heat stroke and hypotension. Medication reconciliation (A) and medical records (E) are secondary.
When a client with thrombocytopenia has a severe headache, the nurse interprets that this may indicate which of the following?
- A. Stress of the disease.
- B. Cerebral bleeding.
- C. Migraine headache.
- D. Sinus congestion.
Correct Answer: B
Rationale: Thrombocytopenia increases the risk of bleeding, and a severe headache may indicate cerebral bleeding, a life-threatening complication. The nurse should prioritize this possibility over stress, migraine, or sinus issues, which are less likely in this context.