Nokea
An older client who had a subtotal parathyroidectomy is preparing for discharge. What finding requires immediate provider notification?
- A. Afebrile with a normal pulse.
- B. No bowel movement since surgery.
- C. No appetite for breakfast.
- D. A positive Chvostek's sign.
Correct Answer: D
Rationale: A positive Chvostek's sign indicates hypocalcemia, a complication after parathyroid surgery that requires immediate attention. This sign is manifested by facial muscle twitching when the facial nerve in front of the ear is tapped, indicating neuromuscular irritability due to low calcium levels. Afebrile with a normal pulse (Choice A) is a normal finding and does not require immediate notification. No bowel movement since surgery (Choice B) is common postoperatively due to anesthesia effects and pain medications and usually resolves within a few days; it does not require immediate notification unless accompanied by other concerning symptoms. No appetite for breakfast (Choice C) is a common postoperative finding and does not require immediate notification unless it persists and leads to dehydration or malnutrition.
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A nurse is working with a new graduate nurse on the delegation of tasks to the unlicensed assistive personnel (UAP). Which task would the new nurse need more teaching about delegating?
- A. Taking a client's blood pressure
- B. Providing oral hygiene for a client
- C. Assessing a client's pain level
- D. Assisting a client with ambulation
Correct Answer: C
Rationale: The correct answer is C: Assessing a client's pain level. This task involves clinical judgment and interpretation, which are within the scope of a licensed nurse's practice. Delegating pain assessment to unlicensed personnel could lead to errors in pain management and inappropriate interventions. Choices A, B, and D involve tasks that can be safely delegated to unlicensed assistive personnel as they do not involve interpretation or nursing judgment. Taking a client's blood pressure, providing oral hygiene, and assisting with ambulation are all routine tasks that can be appropriately assigned to UAP under the supervision of a licensed nurse.
The nurse is caring for a client with a nasogastric tube. Which of the following interventions is a priority to maintain client safety?
- A. Flush the tube with water every 4 hours
- B. Check the tube placement before each feeding
- C. Secure the tube to the client's nose with tape
- D. Keep the head of the bed elevated at 30 degrees
Correct Answer: B
Rationale: Verifying the correct placement of a nasogastric tube before each feeding is essential to prevent aspiration and ensure that the tube is properly positioned in the stomach or intestine. This action is a priority to maintain client safety. Flushing the tube with water every 4 hours is important for tube patency but is not the priority over verifying placement. Securing the tube with tape and keeping the head of the bed elevated are crucial but are considered secondary measures compared to confirming the correct tube placement.
The nurse is teaching a client about lifestyle changes to manage hypertension. Which of the following should be emphasized?
- A. Increase daily intake of sodium.
- B. Exercise regularly and maintain a healthy weight.
- C. Reduce intake of potassium-rich foods.
- D. Drink alcohol in moderation.
Correct Answer: B
Rationale: The correct answer is B. Regular exercise and maintaining a healthy weight are crucial lifestyle changes in managing hypertension. Exercise helps lower blood pressure and improves heart health, while maintaining a healthy weight reduces the risk of hypertension. Choices A, C, and D are incorrect. Increasing daily intake of sodium can elevate blood pressure, reducing intake of potassium-rich foods is not recommended as potassium helps lower blood pressure, and drinking alcohol should be limited or avoided as it can raise blood pressure.
The father of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?
- A. Ensure the client's family is aware of the client's wishes
- B. Begin comfort measures immediately
- C. Obtain a detailed report from the nurse transferring the client
- D. Confirm that the client understands the treatment plan
Correct Answer: C
Rationale: Obtaining a detailed report from the previous nurse ensures continuity of care and that all relevant information is passed on. This is critical in palliative care, where comfort measures and symptom management are key components of care. Choice A is not the most important action in this scenario, as the question focuses on continuity of care within the healthcare team. Beginning comfort measures immediately, as in choice B, is essential but obtaining a detailed report takes precedence to ensure a smooth transition of care. Confirming that the client understands the treatment plan, as in choice D, is important but does not directly address the need for continuity of care through a detailed report.
A client with chronic heart failure is admitted with worsening dyspnea. What is the nurse's priority action?
- A. Administer oxygen at 2 liters per nasal cannula.
- B. Administer a diuretic as prescribed.
- C. Assess the client's lung sounds.
- D. Reposition the client to relieve dyspnea.
Correct Answer: A
Rationale: In a client with chronic heart failure experiencing worsening dyspnea, the priority action for the nurse is to administer oxygen at 2 liters per nasal cannula. This helps improve oxygenation and alleviate respiratory distress. Administering a diuretic (Choice B) may be necessary but addressing oxygenation comes first. While assessing lung sounds (Choice C) is important, it is not the immediate priority when the client is in respiratory distress. Repositioning the client (Choice D) may help with comfort but does not address the underlying issue of inadequate oxygenation.