Nokea
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report?
- A. Calcium level of 9.0 mg/dL
- B. Serum sodium level of 138 mEq/L
- C. Respiratory rate of 18/min
- D. Stridor
Correct Answer: D
Rationale: Stridor is a high-pitched sound that indicates airway obstruction and is the priority finding to report following a thyroidectomy. In this situation, airway compromise is a critical concern that requires immediate intervention to ensure adequate oxygenation. While calcium level (Choice A) and serum sodium level (Choice B) are important assessments post-thyroidectomy, they do not represent an immediate threat to the client's airway. A respiratory rate of 18/min (Choice C) falls within the normal range and does not indicate an immediate risk to the client's airway compared to the presence of stridor.
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A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?
- A. Apply a dry dressing.
- B. Cleanse the wound with normal saline.
- C. Perform debridement as needed.
- D. Apply a hydrocolloid dressing.
Correct Answer: D
Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.
A nurse is caring for a client who is 32 weeks pregnant and has cardiac disease. Which of the following positions should the nurse place the client in to promote optimal cardiac output?
- A. Semi-Fowler's
- B. Supine with head elevated
- C. Left lateral
- D. Right lateral
Correct Answer: C
Rationale: The correct answer is C: Left lateral. Placing the client in the left lateral position helps promote optimal cardiac output during pregnancy by avoiding pressure on the vena cava. This position improves venous return to the heart and subsequently cardiac output. Option A, Semi-Fowler's position, may not be the best choice for a client with cardiac disease as it does not alleviate pressure on the vena cava. Option B, supine with head elevated, can also compress the vena cava, reducing cardiac output. Option D, right lateral position, does not provide the same benefits as the left lateral position for cardiac output during pregnancy.
A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?
- A. Place the client in seclusion when she is confused.
- B. Request a prescription for PRN restraints when the client is wandering.
- C. Dim the lighting in the client's room.
- D. Leave one side rail up on the client's bed.
Correct Answer: C
Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.
While caring for a newborn under phototherapy lights, which of the following is an appropriate nursing action?
- A. Ensure the eye shield is covering the eyes.
- B. Apply lotion to the exposed skin.
- C. Offer glucose water between feedings.
- D. Discontinue breastfeeding during treatment.
Correct Answer: A
Rationale: The correct answer is to ensure the eye shield is covering the eyes. Protecting the newborn's eyes from exposure to direct light is crucial during phototherapy to prevent potential eye damage. Applying lotion to the exposed skin (choice B) is not recommended as it can interfere with the effectiveness of the phototherapy. Offering glucose water between feedings (choice C) is not necessary and may not be suitable for a newborn undergoing treatment. Discontinuing breastfeeding during treatment (choice D) is not recommended as breast milk provides essential nutrients and hydration for the newborn, and breastfeeding should continue unless contraindicated by a specific medical condition.
A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle modifications. Which of the following instructions should be included?
- A. Sleep with the head of the bed elevated.
- B. Avoid drinking fluids with meals.
- C. Eat three large meals each day.
- D. Lie down after eating.
Correct Answer: B
Rationale: The correct instruction for a client with GERD is to avoid drinking fluids with meals. This is because consuming fluids while eating can exacerbate reflux symptoms by increasing stomach distension and contributing to the reflux of stomach contents into the esophagus. Option A is incorrect as elevating the head of the bed can help prevent reflux during sleep, not while drinking fluids. Option C is incorrect as consuming three large meals a day can worsen GERD symptoms due to increased gastric distension. Option D is incorrect as lying down after eating can also worsen GERD symptoms by promoting the reflux of stomach contents into the esophagus.