The client who is post-thyroidectomy complains of numbness a...

The client who is post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should the nurse implement first?

A. Notify the health-care provider immediately.
B. Tap the cheek about two (2) cm anterior to the earlobe.
C. Check the serum calcium and magnesium levels.
D. Prepare to administer calcium gluconate IVP.

Correct Answer: C

Rationale: Numbness and tingling post-thyroidectomy suggest hypocalcemia due to parathyroid injury. Checking serum calcium and magnesium levels confirms the diagnosis before treatment. Notification, Chvostek’s sign, or calcium administration follow confirmation.

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When the nurse reviews the client's medical history, which finding most likely precipitated the present illness?

A. A recent streptococcal throat infection
B. A recent influenza infection
C. A recent episode of gastroenteritis
D. A recent urinary tract infection

Correct Answer: A

Rationale: A recent streptococcal throat infection is a common trigger for acute glomerulonephritis due to immune-mediated kidney damage.

The client is one (1) day postoperative TURP. Which task should the nurse delegate to the UAP?

A. Increase the irrigation fluid to clear clots from the tubing.
B. Elevate the scrotum on a towel roll for support.
C. Change the dressing on the first postoperative day.
D. Teach the client how to care for the continuous irrigation catheter.

Correct Answer: B

Rationale: Elevating the scrotum is a simple supportive task within the UAP’s scope. Adjusting irrigation, changing dressings, and teaching require nursing judgment and are not delegable.

The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement? Select all that apply.

A. Assess the urine in the continuous irrigation drainage bag.
B. Decrease the irrigation fluid in the continuous irrigation catheter.
C. Lower the head of the bed while raising the foot of the bed.
D. Contact the surgeon to give an update on the client’s condition.
E. Check the client’s postoperative creatinine and BUN.

Correct Answer: A,C,D

Rationale: Tachycardia, hypotension, and clammy skin suggest hypovolemic shock, likely from bleeding. Assess urine for blood, use Trendelenburg to improve perfusion, and notify the surgeon. Decreasing irrigation may worsen clotting, and lab checks are less urgent.

The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care? Select all that apply.

A. Monitor vital signs every two (2) hours until stable.
B. Monitor the client’s oral intake and urinary output daily.
C. Administer mouth care when bathing the client.
D. Weigh the client weekly in the same clothing at the same time.
E. Assess skin turgor and mucous membranes every shift.

Correct Answer: A,B,E

Rationale: For fluid volume deficit, monitor vital signs frequently for stability, track intake/output daily to assess hydration, and assess skin turgor/mucous membranes for dehydration. Weekly weights are too infrequent, and mouth care during bathing is not specific.

Which data support to the nurse the client’s diagnosis of acute bacterial prostatitis?

A. Terminal dribbling.
B. Urinary frequency.
C. Stress incontinence.
D. Sudden fever and chills.

Correct Answer: D

Rationale: Acute bacterial prostatitis presents with sudden systemic symptoms like fever and chills, often with dysuria. Terminal dribbling, frequency, and incontinence are more typical of BPH or chronic conditions.