Nokea
The nurse is assessing a client who had a thyroidectomy 12 hours ago and is reporting anxiety, tingling around the mouth, and muscle twitching in the hand. Which of the following actions would be a priority for the nurse to take?
- A. Check the area around the incision site for edema
- B. Review the client’s most recent arterial blood gas results
- C. Evaluate the client’s vocal quality and strength
- D. Obtain a blood specimen to check the serum calcium level
Correct Answer: D
Rationale: Anxiety, tingling, and twitching suggest hypocalcemia from parathyroid damage during thyroidectomy, requiring urgent calcium level assessment. Edema, blood gases, and vocal quality are less urgent.
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The nurse on the mental health unit is leading a group session. Shortly after the session begins, a newly admitted client with schizophrenia stands and starts to leave the room. Which of the following actions should the nurse take?
- A. In a loud, firm voice, direct the client to come back to the room
- B. Gently grasp the client's arm and redirect the client back to the seat
- C. Reinforce the unit rules and importance of attending group sessions
- D. Remain silent and allow the client to leave the room with another staff member
Correct Answer: D
Rationale: Allowing the client to leave with another staff member respects their distress and ensures safety, avoiding confrontation. Loud commands, physical redirection, or rule enforcement may escalate agitation.
Laboratory reference ranges
Hematocrit
Male: 42%-52%
(0.42-0.52)
Female: 37%-47%
(0.37-0.47)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L)
The nurse is reviewing the chart of a client who has a traumatic below-the-knee amputation. Which client should the nurse see first?
- A. Female client who had an arthroscopic rotator cuff repair with sling immobilization and reports moderate swelling and tingling of the hand and fingers
- B. Female client who has a new cast and reports stinging of the hand and fingers and inability to move the toes
- C. Male client who has two new prosthetic legs applied after traumatic below-the-knee amputation and reports crushing pain in the amputated areas
- D. Male client who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L) and is prescribed enoxaparin 1 day after a total hip arthroplasty
Correct Answer: A
Rationale: Stinging and inability to move toes in a new cast suggest compartment syndrome, a surgical emergency. Phantom limb pain and normal hematocrit/enoxaparin are less urgent.
The nurse is caring for a client with a fiberglass cast applied to a distal fracture of the right tibia. The client should be able to bear weight on the cast within:
- A. 10 minutes
- B. 30 minutes
- C. 3 hours
- D. 24 hours
Correct Answer: D
Rationale: Fiberglass casts typically require 24 hours to fully dry and harden before weight-bearing. Choices A, B, and C are too short for the cast to achieve sufficient strength.
The nurse is caring for a client with social anxiety disorder. Which of the following situations would most likely exacerbate the client's symptoms?
- A. Shopping in a crowded grocery store
- B. Moving into a new home with the spouse
- C. Speaking in front of peers at a professional convention
- D. Attending an appointment with a new health care provider
Correct Answer: C
Rationale: Speaking publicly, especially to peers, is highly likely to trigger social anxiety due to fear of scrutiny. Crowded stores, moving, and new providers may cause anxiety but are less intense triggers.
The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?
- A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.
- B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.
- C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.
- D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.
Correct Answer: B
Rationale: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.