Nokea
A client who had a total thyroidectomy this morning is to be admitted to the surgical floor. What should the nurse have readily available when the client arrives?
- A. Tracheostomy set
- B. Catheterization tray
- C. Sterile dressing set
- D. Ventilator
Correct Answer: A
Rationale: Thyroidectomy risks airway obstruction from swelling or hematoma; a tracheostomy set is essential for emergency airway management.
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A nurse is caring for a pregnant patient in her third trimester. Which of the following findings should be reported immediately?
- A. Mild edema in the lower extremities
- B. Heartburn
- C. Severe headache and visual disturbances
- D. Frequent urination
Correct Answer: C
Rationale: Severe headache and visual disturbances suggest preeclampsia, a medical emergency. Mild edema, heartburn, and frequent urination are normal in late pregnancy.
Teaching about the need to avoid foods high in potassium is most important for which client?
- A. a client receiving diuretic therapy
- B. a client with an ileus
- C. a client with metabolic alkalosis
- D. a client with renal disease
Correct Answer: D
Rationale: Renal disease impairs potassium excretion, leading to hyperkalemia, so avoiding high-potassium foods is critical. The other conditions are more associated with hypokalemia. Physiological Adaptation
Ms. L had a C-section done. She delivered a healthy baby boy. On her 1st post operative day, Ms. L's roommate called the nurse & reports that Ms. L was very anxious & pale looking. Other clients were in Ms. L's room trying to help out. Upon assessment, her BP was 80/60, HR 110bpm.
The top nursing priority includes:
- A. monitor the patient's v/s & notify the doctor stat
- B. Clear the patient's immediate environment & ask other clients to move away
- C. Place the patient in flat position and check her abdominal dressing.
- D. Get the crash cart in anticipation for cardiac arrest
Correct Answer: A
Rationale: Hypotension and tachycardia suggest postpartum hemorrhage, requiring immediate physician notification.
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to receive Stadol 2 mg IM. Before administering these medications, the nurse should
- A. obtain respirations and temperature.
- B. dilute with 9 ml of NS.
- C. draw the medications in separate syringes.
- D. verify the route of administration.
Correct Answer: C
Rationale: Compazine (prochlorperazine) is incompatible with most medications, including Stadol (butorphanol), in the same syringe, as mixing may cause precipitation or reduced efficacy. Drawing them in separate syringes ensures safe administration. Monitoring vital signs (A) is less critical, dilution (B) is inappropriate, and verifying the route (D) is unnecessary as IM is specified.
Which condition is associated with inadequate intake of vitamin C?
- A. rickets
- B. marasmus
- C. kwashiorkor
- D. scurvy
Correct Answer: D
Rationale: Scurvy results from vitamin C deficiency, causing symptoms like bleeding gums and poor wound healing. The other conditions are related to different nutritional deficiencies. Physiological Adaptation