Nokea
A nurse is collecting data from a client who underwent a thyroidectomy 4 hr ago. Which of the following client findings indicates a complication of the procedure?
- A. Soreness at the incision site
- B. Serosanguineous drainage on the dressing
- C. Report of sore throat
- D. Tingling of the fingers
Correct Answer: D
Rationale: Tingling of the fingers suggests hypocalcemia due to parathyroid gland damage during thyroidectomy, a potential complication.
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A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?
- A. Perform suctioning.
- B. Instill saline into the tubing.
- C. Increase the humidification.
- D. Check the cuff pressure.
Correct Answer: A
Rationale: Restlessness and crackles in the lungs suggest secretions in the airway, and suctioning is the appropriate intervention to clear them in a client with a tracheostomy.
A nurse is collecting data from a client who is taking enoxaparin. The client reports starting the use of dietary supplements. The nurse should report the use of which of the following supplements to the provider?
- A. Ginkgo biloba
- B. Flaxseed powder
- C. Probiotics
- D. Echinacea
Correct Answer: A
Rationale: Ginkgo biloba can increase the risk of bleeding when taken with enoxaparin, an anticoagulant, and should be reported to the provider.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced.
A nurse is assisting in the care of a client who The first action the nurse should take is to followed by. is postoperative following an open reduction internal fixation of the right tibia. Complete the following sentence by using the lists of options. The first action the nurse should take is to..... followed by.....
- A. Assess neurovascular status.
- B. Elevate the leg.
- C. Administer prescribed pain medication
- D. Monitor vital signs
- E. Apply a sterile dressing to the wound
- F. Notify the provider
Correct Answer: A,F
Rationale: Assessing neurovascular status first identifies complications like compartment syndrome, followed by notifying the provider for urgent intervention.
A nurse is reinforcing teaching about saturated fats with a client who is at risk for cardiovascular disease. Which of the following cooking fats should the nurse recommend the client use?
- A. Canola oil
- B. Butter
- C. Vegetable shortening
- D. Lard
Correct Answer: A
Rationale: Canola oil is low in saturated fat and heart-healthy, unlike butter, shortening, or lard, reducing cardiovascular risk.
A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter.
- A. Apply pressure to the venipuncture site with sterile gauze.
- B. Perform hand hygiene.
- C. Clamp the IV tubing.
- D. Withdraw the catheter from the client's vein.
- E. Remove the dressing and tape from the venipuncture site.
Correct Answer: B,E,C,A,D
Rationale: The sequence is: hand hygiene, remove dressing/tape, clamp tubing, apply pressure, withdraw catheter-ensuring safety and preventing bleeding.