Nokea
The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans on obtaining an order to assess the client's serum
- A. potassium level
- B. calcium level
- C. sodium level
- D. glucose level
Correct Answer: B
Rationale: Total thyroidectomy can disrupt parathyroid function, leading to hypocalcemia due to decreased parathyroid hormone. Monitoring serum calcium levels is critical to detect and manage this complication. Potassium, sodium, and glucose levels are less directly affected by thyroidectomy.
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The nurse recognizes which of the following treatments are alternative treatments for anxiety. Select all that apply.
- A. Black cohosh
- B. Ginger
- C. St. John's wort
- D. Kava
- E. Passion flower
Correct Answer: D,E
Rationale: Kava and passion flower are used for anxiety relief. Black cohosh treats menopausal symptoms, ginger aids nausea, and St. John’s wort is for depression.
The nurse in the postanesthesia care unit (PACU) cares for a client who had an appendectomy. Which of the following client assessments warrants immediate follow-up?
- A. has breath sounds that are high-pitched and crowing
- B. reports incisional pain at a level of '5' on a scale of 0 (no pain) to 10 (severe pain)
- C. has a capillary blood glucose of 115 mg/dL [70-110 mg/dL]
- D. reports persistent nausea following the administration of an anti-emetic
Correct Answer: A
Rationale: High-pitched, crowing breath sounds suggest airway obstruction or stridor, a critical finding requiring immediate intervention to ensure airway patency. Moderate pain, slightly elevated glucose, and nausea are less urgent.
The nurse supervises a student assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse
- A. Puts the client's affected (weaker) arm in the shirt's sleeve first.
- B. Places shoes with velcro straps on the client's feet.
- C. Places the wheelchair as close to the bed as possible on the client's affected (weaker) side.
- D. Places the hairbrush in the client's unaffected (stronger) hand.
Correct Answer: C
Rationale: Wheelchair on the affected side hinders transfer; it should be on the unaffected side. Dressing the weaker arm first, velcro shoes, and stronger hand use are correct.
The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
- A. Legumes
- B. Almond butter
- C. Grilled chicken
- D. Apricots
- E. Baked fish
- F. Seafood salad
Correct Answer: A,B,D
Rationale: Vegetarian diets exclude meat, so legumes, almond butter, and apricots are suitable. Chicken, fish, and seafood are not vegetarian.
The nurse is preparing a client for a clinical breast exam by the physician. To facilitate an effective exam, the nurse should position the client
- A. Supine with arms at the side and a pillow under both knees
- B. Left lateral with the head resting on a pillow and the arm over the head
- C. Sitting forward with a pillow behind the shoulder blades with hands on the hips
- D. Supine, with the arm on the side raised behind the head, and a small pillow under the shoulder
Correct Answer: D
Rationale: Supine with the arm raised and a pillow under the shoulder flattens the breast tissue, facilitating palpation. Other positions are less effective for breast exams.