Nokea
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following interventions is the highest priority?
- A. Administer oxygen.
- B. Prepare for needle decompression.
- C. Obtain a chest X-ray.
- D. Start an IV line.
Correct Answer: B
Rationale: Preparing for needle decompression is the highest priority in tension pneumothorax to relieve pressure and restore lung function.
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A client returning from the postanesthesia care unit after transurethral resection of the prostate (TURP) has bladder irrigation running via a 3-way Foley catheter. The nurse should notify the primary health care provider if which color of urine is noted in the urinary drainage bag?
- A. Pale pink
- B. Bright red
- C. Dark pink
- D. Tea-colored
Correct Answer: B
Rationale: Bright red bleeding should be reported because it could indicate complications related to active bleeding. If the bladder irrigation is infusing at a sufficient rate, the urinary drainage will be pale pink. A dark pink color (sometimes referred to as punch-colored) indicates that the speed of the irrigation should be increased. Tea-colored urine is not seen after TURP but may be noted in the client with renal failure or other renal disorders.
The nurse is caring for a client who has just undergone a mastectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage arm exercises on the affected side.
- B. Keep the affected arm dependent.
- C. Apply heat to the surgical site.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Encouraging arm exercises prevents lymphedema and promotes circulation post-mastectomy.
A client with a history of rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hyperkalemia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, requiring regular liver function tests.
Which clinical manifestations are consistently observed in infants who have been diagnosed with congenital hypothyroidism? Select all that apply.
- A. Irritability
- B. Hoarse cry
- C. Bradycardia
- D. Constipation
- E. Fused fontanels
- F. Excessive sleeping
Correct Answer: B,C,D,F
Rationale: The infant with congenital hypothyroidism may display the following signs: skin mottling, a large fontanel, a large tongue, hypotonia, slow reflexes, bradycardia, and a distended abdomen. Other signs and symptoms include prolonged jaundice, lethargy, constipation, feeding problems, coldness to touch, umbilical hernia, hoarse cry, and excessive sleeping.
A client with a history of chronic kidney disease is prescribed sevelamer (Renagel). The nurse should explain that this medication works by:
- A. Reducing blood pressure.
- B. Binding phosphate in the gut.
- C. Increasing urine output.
- D. Decreasing blood glucose.
Correct Answer: B
Rationale: Sevelamer binds phosphate in the gut, reducing serum phosphate levels in chronic kidney disease.