Nokea
An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
- A. in semi-Fowler’s position.
- B. prone, with the head turned to the side.
- C. with the head of the bed elevated 45° and the neck extended.
- D. supine, with the head in the midline position.
Correct Answer: A
Rationale: check vital signs every 15 minutes until stable, assess for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema or laryngospasm)
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The nurse is caring for a female client following the removal of the parathyroid glands. The client complains of a 'pins and needles' sensation and difficulty swallowing lunch. The nurse would expect which laboratory value to be abnormal?
- A. calcium
- B. potassium
- C. magnesium
- D. blood glucose
Correct Answer: A
Rationale: Parathyroidectomy can cause hypocalcemia, leading to paresthesia ('pins and needles') and dysphagia due to muscle dysfunction.
A client is transferred to the intensive care unit following a conornary artery bypass graft. Which one of the post-surgical assessments should be reported to the physician?
- A. Urine output of 50 ml in the past hour
- B. Temperature of 99°F
- C. Strong pedal pulses bilaterally
- D. Central venous pressure 15 mmHâ‚‚O
Correct Answer: D
Rationale: A central venous pressure of 15 mmHâ‚‚O is elevated, indicating potential fluid overload or cardiac issues, requiring reporting.
A client is being discharged on Coumadin after hospitalization for a deep vein thrombosis. The nurse recognizes that which food would be restricted while the client is on this medication?
- A. Lettuce
- B. Apples
- C. Potatoes
- D. Macaroni
Correct Answer: A
Rationale: Lettuce, especially leafy greens, is high in vitamin K, which can antagonize Coumadin's anticoagulant effect, requiring dietary restriction or monitoring.
The nurse is assigned a male client with a long-term in-dwelling catheter for incontinence. The nurse plans on performing which of the following to prevent complications?
- A. perform perineal care using sterile technique
- B. irrigate daily with 60 cc normal saline
- C. restrict fluids to 1,500 cc/day
- D. stabilize the catheter on the abdomen
Correct Answer: D
Rationale: Stabilizing the catheter prevents traction and urethral trauma. Perineal care uses clean technique, routine irrigation is unnecessary, and fluid restriction is inappropriate.
The nurse is reviewing medication orders for his clients. Which order would necessitate contacting the health care provider?
- A. Paxil (paroxetine) 20 mg PO daily for a 57-year-old client with social anxiety disorder
- B. Phenergan (promethazine hydrochloride) 12.5 mg PR q12h prn for a child with Reye's syndrome
- C. Diflucan (fluconazole) 150 mg x 1 dose PO for a 24-year-old client with vaginal candidiasis
- D. Lopressor (metoprolol tartrate) 50 mg PO daily for a 48-year-old client with hypertension
Correct Answer: B
Rationale: Promethazine is contraindicated in children with Reye’s syndrome due to the risk of worsening neurological symptoms. Other orders are appropriate.