Nokea
The client with Hodgkin's disease undergoes an excisional cervical lymph node biopsy under local anesthesia. After the procedure, which does the nurse assess first?
- A. Vital signs.
- B. The incision.
- C. The airway.
- D. The neurologic signs.
Correct Answer: C
Rationale: After a cervical lymph node biopsy, the nurse should first assess the airway, as swelling or hematoma in the neck could compromise breathing. Vital signs, incision, and neurologic signs are assessed next.
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Which assessment is critical for a client receiving thrombolytic therapy?
- A. Blood glucose.
- B. Blood pressure.
- C. Temperature.
- D. Cholesterol level.
Correct Answer: B
Rationale: Blood pressure is critical to monitor during thrombolytic therapy to prevent hemorrhagic complications.
A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client:
- A. Adds dried fruit to cereal and baked goods.
- B. Cooks tomato-based foods in iron pots.
- C. Drinks coffee or tea with meals.
- D. Adds vitamin C to all meals.
Correct Answer: C
Rationale: Drinking coffee or tea with meals inhibits iron absorption due to tannins, which bind to iron and reduce its bioavailability. This indicates a lack of understanding of nutritional counseling for anemia, as the client should avoid these beverages during meals. Adding dried fruit (iron source), cooking in iron pots (increases iron content), and consuming vitamin C (enhances iron absorption) are appropriate strategies.
A client post-ureteroscopy reports burning on urination. The nurse should:
- A. Encourage fluids.
- B. Administer antibiotics.
- C. Apply a heating pad.
- D. Notify the physician.
Correct Answer: A
Rationale: Burning is common post-ureteroscopy; fluids dilute urine, reducing irritation.
Which of the following is the most common initial manifestation of acute renal failure?
- A. Dysuria.
- B. Anuria.
- C. Hematuria.
- D. Oliguria.
Correct Answer: D
Rationale: Oliguria, reduced urine output, is the most common initial sign of acute renal failure due to impaired kidney filtration.
A client scheduled for a cholecystectomy expresses fear about postoperative pain. Which nursing action is most appropriate?
- A. Administer preoperative analgesics as ordered.
- B. Teach the client about pain management options.
- C. Reassure the client that pain is minimal after surgery.
- D. Refer the client to a pain management specialist.
Correct Answer: B
Rationale: Teaching the client about pain management options, such as PCA or oral analgesics, empowers them to understand and cope with postoperative pain, reducing anxiety. Administering analgesics may not be ordered preoperatively, and reassurance without education is inadequate.