Nokea
The nurse is caring for a client following removal of the thyroid. Immediately post-op the nurse should:
- A. Maintain the client in a semi-Fowler's position with her head and neck supported by pillows.
- B. Encourage the client to turn her head side to side to promote drainage of oral secretions.
- C. Maintain the client in a supine position with sandbags placed on either side of her head and neck.
- D. Encourage the client to cough and deep breathe every 2 hours with her neck in a flexed position.
Correct Answer: A
Rationale: Semi-Fowler's position reduces swelling and supports the surgical site post-thyroidectomy. Turning the head or flexing the neck risks wound dehiscence. Supine with sandbags is unnecessary and uncomfortable.
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The nurse is caring for clients in a rehabilitation facility. The nursing team reports that a client recovering from a hip fracture has repeatedly 'transferred herself to the floor.' Which of the following actions, if taken by the nurse, is BEST?
- A. Place the call light within the client's reach.
- B. Remove the footrests from the wheelchair.
- C. Observe the client trying to rise from a sitting to a standing position.
- D. Place a posey vest restraint on the client.
Correct Answer: C
Rationale: Observing the client’s transfer technique identifies the cause of falls, guiding interventions. Options A, B, and D are premature or restrictive.
The nurse is caring for a client with a history of anxiety disorder.
- A. Which intervention is most effective for managing acute anxiety in a client?
- B. Administer a benzodiazepine as ordered.
- C. Encourage deep breathing exercises.
- D. Restrict the client to their room.
- E. Provide a high-stimulus environment.
Correct Answer: B
Rationale: Deep breathing exercises calm the autonomic nervous system, reducing acute anxiety effectively and non-invasively. Benzodiazepines are used cautiously, isolation increases anxiety, and high-stimulus environments worsen it.
A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
- A. Converse with the client to determine if the mucous membranes are impaired
- B. Report output of less than 30 ml/hr
- C. Provide oral fluids every hour
- D. Check skin turgor every 4 hours
Correct Answer: C
Rationale: Providing oral fluids is a routine task with predictable outcomes, suitable for a UAP, while the other tasks require clinical judgment or assessment skills.
The nurse is caring for a client with a history of breast cancer.
- A. Which symptom should the nurse report immediately for a client with a history of breast cancer?
- B. Mild fatigue after chemotherapy.
- C. A new lump in the axillary region.
- D. Occasional nausea.
- E. Hair loss.
Correct Answer: B
Rationale: A new lump in the axillary region may indicate lymph node metastasis, requiring immediate evaluation. Fatigue, nausea, and hair loss are expected chemotherapy side effects.
The nurse is caring for a client who is postoperative day 1 after a mitral valve replacement. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Heart rate of 90 bpm.
- C. Chest tube drainage of 100 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-valve replacement due to risk of endocarditis, requiring immediate evaluation. Options B, C, and D are expected or normal: heart rate 90 bpm, drainage 100 mL/hour, and blood pressure 130/80 mmHg are stable.