Nokea
The nurse is caring for a client post-thyroidectomy. Which assessment finding requires immediate intervention?
- A. Mild incisional pain
- B. Tingling in the fingers
- C. Slight hoarseness
- D. Temperature of 99.5°F
Correct Answer: B
Rationale: Tingling in the fingers suggests hypocalcemia due to parathyroid gland damage, risking tetany or seizures, requiring immediate intervention. Pain (A), hoarseness (C), and mild fever (D) are expected post-op.
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A client with a history of a bone marrow transplant is receiving immunosuppressive therapy. The nurse should monitor the client for:
- A. Infection
- B. Hypotension
- C. Hyperglycemia
- D. Hair loss
Correct Answer: A
Rationale: Immunosuppressive therapy post-bone marrow transplant increases infection risk due to suppressed immunity. Hypotension, hyperglycemia, and hair loss are less immediate concerns.
The client is admitted with a diagnosis of acute diverticulitis. Which dietary order should the nurse anticipate?
- A. High-fiber diet
- B. Low-residue diet
- C. Clear liquid diet
- D. Regular diet
Correct Answer: C
Rationale: A clear liquid diet is ordered during acute diverticulitis to rest the bowel and reduce irritation. High-fiber is for prevention, low-residue is for chronic management, and regular diets are inappropriate.
Which food selection would provide the most calcium for a client who is four months pregnant?
- A. Bowl of oatmeal
- B. Bran muffin
- C. One cup of yogurt
- D. Large orange
Correct Answer: C
Rationale: Yogurt is a rich source of calcium essential for fetal bone development during pregnancy. One cup provides approximately 300-400 mg of calcium significantly more than oatmeal bran muffins or oranges.
A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:
- A. Push during contractions
- B. Hyperventilate during contractions
- C. Walk between contractions
- D. Relax during contractions
Correct Answer: A
Rationale: The second stage of labor is marked by full cervical dilation and the urge to push with contractions.
A client with a history of heart failure is receiving Spironolactone (Aldactone). The nurse should teach the client to:
- A. Avoid potassium-rich foods
- B. Increase sodium intake
- C. Take the medication at bedtime
- D. Limit fluid intake
Correct Answer: A
Rationale: Spironolactone, a potassium-sparing diuretic, risks hyperkalemia, so potassium-rich foods should be avoided. Sodium restriction, daytime dosing, and fluid management are secondary.