Nokea
The nurse is assessing a client with Graves' disease. Which assessment finding would the nurse expect in this client?
- A. bradycardia
- B. constipation
- C. exophthalmos
- D. recent weight gain
Correct Answer: C
Rationale: Graves' disease, a form of hyperthyroidism, causes exophthalmos (C) due to orbital tissue inflammation. Bradycardia (A), constipation (B), and weight gain (D) are associated with hypothyroidism.
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A client with third- and fourth-degree burns is in the burn unit. The nurse understands that which of the following is true regarding fluid shift in burn clients?
- A. The fluid shift can cause hypokalemia and hypovolemia.
- B. Hemoconcentration increases blood flow and reduces blood viscosity.
- C. Excessive weight loss can occur during the first 12 hours post burn due to the fluid shift.
- D. Severe edema can occur in areas that were not burned, due to the leakage of electrolytes and fluids from the vascular space.
Correct Answer: D
Rationale: Burns cause fluid leakage, leading to severe edema even in unburned areas (D). Hyperkalemia (not hypokalemia, A), increased viscosity (B), and weight gain (not loss, C) occur.
The nurse is caring for a client with a Braden score of 13. How does the nurse interpret this client's risk of skin breakdown?
- A. high risk
- B. mild risk
- C. severe risk
- D. moderate risk
Correct Answer: A
Rationale: A Braden score of 13 indicates high risk (A) for skin breakdown (scores ≤14). Mild (B), severe (C), and moderate (D) do not align with standard Braden scale interpretations.
The nurse is caring for a client who just returned from a right mastectomy. Which position does the nurse anticipate for the client?
- A. high Fowler's with the unaffected arm elevated on a pillow
- B. flat with the client positioned on the affected side or back
- C. semi-Fowler's with the affected arm supported on a pillow
- D. reverse Trendelenburg's with the arm on the affected side supported on a pillow
Correct Answer: C
Rationale: Semi-Fowler's with the affected arm supported (C) promotes comfort and reduces lymphedema risk post-mastectomy. High Fowler's (A), flat (B), and reverse Trendelenburg's (D) are less optimal.
The nurse is preparing to extubate a client. Arrange in order of priority the actions that the nurse should take to perform this procedure.
- A. hyperoxygenate the client
- B. explain the procedure to the client
- C. immediately instruct the client to cough
- D. apply oxygen by nasal cannula or face mask
- E. thoroughly suction the ET tube and the oral cavity
- F. teach the client how to use an incentive spirometer every 2 hours
- G. set up oxygen/emergency equipment
Correct Answer: B,F,A,E,G,C,D
Rationale: Explain procedure (B) to prepare client,(F) set up oxygen/emergency equipment , hyperoxygenate (A), suction (E), deflate cuff/remove tube (G), instruct to cough (C), apply oxygen (D), teach spirometer use
The ED nurse has admitted a client who is homeless and was found unresponsive in the street during below freezing temperatures. The client is diagnosed with severe hypothermia. The nurse should implement which measures for this client? Select all that apply.
- A. apply a heating blanket
- B. obtain an oral temperature
- C. assess level of consciousness
- D. position in the supine position
- E. massage the extremities vigorously
- F. prepare to administer CPR if indicated
Correct Answer: A,C,D,F
Rationale: Heating blanket (A), assessing consciousness (C), supine position (D), and preparing for CPR (F) are appropriate for severe hypothermia. Oral temperature (B) is inaccurate, and vigorous massage (E) risks tissue damage.