Nokea
The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?
- A. A tracheotomy set
- B. A padded tongue blade
- C. An endotracheal tube
- D. An airway
Correct Answer: A
Rationale: A tracheotomy set is kept at the bedside post-thyroidectomy due to the risk of airway obstruction from swelling or hematoma.
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A client is complaining of chest pain. Nursing assessment reveals a BP of 78/40, shortness of breath, and third-degree AV block on the heart monitor. What medication would the nurse prepare for initial administration?
- A. Atropine
- B. Verapamil (Calan)
- C. Lidocaine (Xylocaine)
- D. Procainamide (Pronestyl)
Correct Answer: A
Rationale: Third-degree AV block with hypotension (BP 78/40) requires atropine to increase heart rate by blocking vagal activity, improving cardiac output.
The nurse is assessing elderly clients at a community center. Which of the following findings would be the most cause for concern?
- A. Complaint of dry mouth
- B. Loss of 1 inch of height in the last year
- C. Stiffened joints
- D. Rales bilaterally on chest auscultation
Correct Answer: D
Rationale: Rales bilaterally on chest auscultation suggest fluid in the lungs, which could indicate serious conditions like heart failure or pneumonia, requiring immediate attention. Dry mouth, height loss, and stiffened joints are common in aging but less urgent.
The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
- A. Negligence
- B. Tort
- C. Assault
- D. Malpractice
Correct Answer: D
Rationale: Malpractice involves professional negligence causing harm, as in administering an incorrect dose of medication.
The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
- A. Assess for tube placement by aspirating stomach content
- B. Place the patient in a left-lying position
- C. Administer feeding with 50% Dextrose
- D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes
Correct Answer: A
Rationale: Aspirating stomach content confirms nasogastric tube placement, preventing aspiration.
A client is admitted with suspected Hodgkin's lymphoma. The diagnosis is confirmed by the:
- A. Overproliferation of immature white cells
- B. Presence of Reed-Sternberg cells
- C. Increased incidence of microcytosis
- D. Reduction in the number of platelets
Correct Answer: B
Rationale: Hodgkin's lymphoma is diagnosed by the presence of Reed-Sternberg cells, large abnormal cells found in lymph node biopsies.