Nokea
A client with multiple myeloma is admitted with a serum calcium level of 13.2 mg/dL. Which of the following nursing interventions is the priority?
- A. Administer oral calcium supplements.
- B. Encourage ambulation.
- C. Administer I.V. normal saline.
- D. Restrict fluid intake.
Correct Answer: C
Rationale: Hypercalcemia (serum calcium >10.5 mg/dL) in multiple myeloma requires urgent I.V. normal saline to promote calcium excretion and prevent renal damage, making it the priority intervention.
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A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Which of the following interventions is most important for the nurse to implement in the preoperative period?
- A. Assess the temperature in the affected area
- B. Monitor the radial pulse in the affected arm
- C. Protect the extremity from cold
- D. Avoid using the arm for a venipuncture
Correct Answer: D
Rationale: Avoiding venipuncture in the affected arm is critical preoperatively to preserve vascular integrity and prevent complications (e.g., hematoma) that could affect the axillary-to-axillary bypass surgery. Monitoring pulses, assessing temperature, and protecting from cold are important but less urgent than preventing vascular trauma.
A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first?
- A. IV fluid rate
- B. Pedal pulses
- C. Nasal cannula flow rate
- D. Capillary refill
Correct Answer: B
Rationale: A significant drop in blood pressure post-femoral-popliteal bypass graft suggests possible hypoperfusion or graft occlusion. Assessing pedal pulses first is critical to ensure the graft is patent and blood flow is restored to the lower extremity. Compromised pulses could indicate graft failure, requiring immediate intervention. IV fluid rate, nasal cannula flow rate, and capillary refill are secondary considerations after confirming vascular patency.
After an inguinal herniorrhaphy, the nurse should assess the client carefully for which of the following likely complications?
- A. Pneumonia.
- B. Deep vein thrombosis.
- C. Paralytic ileus.
- D. Urine retention.
Correct Answer: D
Rationale: Urine retention is a likely complication after inguinal herniorrhaphy due to anesthesia, pain, or surgical manipulation near the bladder. Pneumonia, deep vein thrombosis, and paralytic ileus are less specific to this surgery. CN: Physiological adaptation; CL: Analyze
A male client with a head injury regains consciousness and the normal loss. Which of the following nursing statements is most appropriate as the client awakens?
- A. I'll get your family.
- B. Can you tell me your name and where you live?
- C. I'll bet you're a little confused right now.
- D. You are in the hospital. You were in an accident and unconscious.
Correct Answer: D
Rationale: Providing clear, concise orientation information is most appropriate for a client regaining consciousness to reduce confusion and anxiety. Calling family, asking for personal details, or assuming confusion may overwhelm or distress the client.
If the client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan?
- A. Review the negative effects of smoking on the body.
- B. Discuss the effects of passive smoking on environmental pollution.
- C. Establish the client's daily smoking pattern.
- D. Explain how smoking worsens high blood pressure.
Correct Answer: C
Rationale: Establishing the daily smoking pattern identifies triggers and habits, forming the basis for a tailored cessation plan.