Nokea
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?
- A. Gag reflex
- B. Warmth of extremities
- C. Temperature
- D. Level of pain
Correct Answer: A
Rationale: The correct answer is A: Gag reflex. The priority assessment for a client post-endoscopy with sedation is to ensure their airway is intact. The presence of a gag reflex indicates the airway protection mechanism is functional, reducing the risk of aspiration. Monitoring warmth of extremities, temperature, and pain level are important but secondary assessments compared to airway patency. Ensuring the client's safety and preventing respiratory compromise take precedence in this situation.
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A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
- A. The client's capillary refill in the left toe is 6 seconds.
- B. The client has 100 mL blood in the closed-suction drain.
- C. The client has an oral temperature of 38.3°C (100.9°F).
- D. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
Correct Answer: A
Rationale: The correct answer is A because a capillary refill of 6 seconds in the left toe indicates poor circulation, which could lead to ischemia or necrosis in the extremity. Immediate intervention is necessary to prevent further complications.
Choice B is not as urgent as it involves monitoring and managing drainage, which can be addressed after the circulation concern is addressed.
Choice C, an elevated temperature, may indicate infection but is not as immediately life-threatening as poor circulation.
Choice D, pain at the operative site, is important but does not require immediate intervention as it can be managed with pain medication.
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
- A. Administer antihypertensive medications.
- B. Maintain the client on NPO status.
- C. Place the client in a supine position.
- D. Monitor the client for hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, and digestion should be minimized to reduce pancreatic enzyme secretion. Keeping the client on NPO status allows the pancreas to rest and reduces stimulation of enzyme production. Administering antihypertensive medications (A) is not directly related to pancreatitis care. Placing the client in a supine position (C) may not be comfortable and can exacerbate pain. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a priority in acute cases.
A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?
- A. Joint inflammation
- B. Bull's eye lesion
- C. Esophagitis
- D. Tophi
Correct Answer: A
Rationale: The correct answer is A: Joint inflammation. Systemic lupus erythematosus commonly affects the joints, leading to inflammation and pain. This is known as lupus arthritis. Other choices are incorrect: B (Bull's eye lesion) is associated with Lyme disease, C (Esophagitis) is inflammation of the esophagus which is not a common manifestation of lupus, and D (Tophi) are uric acid crystal deposits seen in gout, not lupus.
A nurse is reviewing the laboratory findings of a client who has a new diagnosis of Graves' disease. The nurse should anticipate which of the following laboratory values to be elevated?
- A. Trisodothyronine 3
- B. Phosphorus
- C. Calcium
- D. Thyroid-stimulating hormone
Correct Answer: A
Rationale: The correct answer is A: Trisodothyronine 3. In Graves' disease, there is excessive production of thyroid hormones, including triiodothyronine (T3). Elevated T3 levels are common in hyperthyroidism, which is a hallmark of Graves' disease. T3 is the active form of thyroid hormone and is responsible for regulating metabolism. Phosphorus, calcium, and thyroid-stimulating hormone levels are typically not elevated in Graves' disease. Phosphorus and calcium are more related to bone health and are usually within normal limits unless complications arise. Thyroid-stimulating hormone levels are usually suppressed in hyperthyroidism, including Graves' disease.
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?
- A. I can arrange for a social worker to talk to you before you leave.
- B. I can contact the occupational therapist to schedule a home visit.
- C. Contact your pharmacy to inquire about a different medication.
- D. You should ask your provider to prescribe a cheaper medication.
Correct Answer: A
Rationale: The correct answer is A because the nurse should address the client's financial concerns by offering a social worker to assist with resources. This option demonstrates holistic care and supports the client's well-being beyond the medical aspect. Option B is irrelevant as it does not address the medication affordability issue. Option C puts the burden on the client to find a solution. Option D is not appropriate as the client may not feel comfortable asking for a cheaper medication directly.