Nokea
The nurse is aware that which of the following assessments would be indicative of hypocalcemia?
- A. Constipation.
- B. Depressed reflexes.
- C. Decreased muscle strength.
- D. Positive Trousseau's sign.
Correct Answer: D
Rationale: positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia
You may also like to solve these questions
A newly diagnosed diabetic is learning to administer her injections of NPH and regular insulin. Which statement indicates that the client understands the nurse's teaching regarding proper insulin administration?
- A. I will administer the NPH and regular insulin in two separate injections.
- B. I will withdraw the dose of regular insulin before withdrawing the NPH insulin.
- C. It does not matter which insulin is withdrawn first as long as the amount is correct.
- D. I will withdraw the dose of NPH insulin before withdrawing the regular insulin.
Correct Answer: B
Rationale: When mixing NPH and regular insulin, regular insulin (clear) should be withdrawn first to avoid contaminating it with NPH (cloudy). Separate injections are not standard. Order matters (C is incorrect). Withdrawing NPH first risks contamination.
The nurse is caring for all of the following clients. Who is probably at greatest risk for skin breakdown and will need special nursing care measures?
- A. A 75-year-old who is admitted with a broken hip
- B. An 80-year-old who is admitted with angina
- C. An 85-year-old who is admitted for diagnostic tests
- D. A 78-year-old who is admitted with asthma
Correct Answer: A
Rationale: A broken hip limits mobility, increasing pressure ulcer risk due to prolonged immobility, requiring special skin care measures.
An adult who has just been diagnosed with pulmonary tuberculosis asks the nurse how long he will have to be in isolation. What should be included in the nurse's reply?
- A. Isolation is for the duration of the treatment, which is at least 26 weeks.
- B. Isolation is necessary as long as the client has a cough.
- C. When the client has three negative sputum specimens, isolation is discontinued.
- D. When the evening fevers and night sweats subside, isolation is discontinued.
Correct Answer: C
Rationale: Isolation for pulmonary TB ends when three consecutive sputum samples are negative, indicating non-infectiousness, typically before the full 6-month treatment.
The nurse is caring for a client who is postoperative day 1 after a cholecystectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site
- B. Temperature of 100.8°F (38.2°C)
- C. Bile-colored drainage from the T-tube
- D. Urine output of 40 mL/hour
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-cholecystectomy complication. Options A, C, and D are normal: pain is expected, bile drainage is typical, and urine output is adequate.
The nurse is caring for a post-operative client who develops a wound evisceration. The first nursing intervention should be
- A. medicate the client for pain
- B. call the provider
- C. cover the wound with sterile saline dressing
- D. place the bed in a flat position
Correct Answer: C
Rationale: When evisceration occurs, the wound should first be quickly covered by sterile dressings soaked in sterile saline. This prevents tissue damage until a repair can be effected.