Nokea
The nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?
- A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone
- B. Observe for swelling of the neck, tracheal deviation, and severe pain
- C. Evaluate the quality of the client’s voice postoperatively, noting any dastric changes
- D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes
Correct Answer: D
Rationale: The correct answer is D: Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. After a thyroidectomy, the parathyroid glands may be inadvertently damaged, leading to hypocalcemia. Muscle twitching and numbness/tingling are early signs of hypocalcemia. The nurse should monitor for these symptoms to detect and address hypocalcemia promptly.
Choice A is incorrect as monitoring thyroid-stimulating hormone levels is not related to hypocalcemia. Choice B is incorrect as it describes signs of potential complications like bleeding or airway obstruction, not hypocalcemia. Choice C is incorrect as changes in voice quality and gastric issues are not specific to hypocalcemia.
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An adult is to receive narcotic analgesics via patient controlled analgesia. The nurse is evaluating client’s understanding of the procedure. Which of the following statements by the client indicates that she understand PCA?
- A. When I press this button the machine will always give me more medicine.
- B. I will press the button whenever I feel pain
- C. I should press this button every hour so the pain doesn’t come back
- D. With this machine I will experience no more pain
Correct Answer: B
Rationale: The correct answer is B: "I will press the button whenever I feel pain." This answer demonstrates understanding of how patient-controlled analgesia (PCA) works, where the client self-administers medication when needed for pain relief. Option A is incorrect as the machine is programmed with lockout intervals to prevent overdosing. Option C is incorrect as the client should only press the button when experiencing pain, not on a fixed schedule. Option D is incorrect as PCA does not guarantee complete pain elimination. The key in PCA is empowering the client to self-administer medication based on their pain level.
In which of the ff circumstances should a nurse avoid using midline and mid clavicular sites for IV therapy? Choose all that apply.
- A. To administer solutions with a pH greater than 5 and less than 9
- B. To administer antineoplastic chemotherapy
- C. To administer slow, low-volume infusions
- D. To administer high-pressure bolus injections
Correct Answer: B
Rationale: The correct answer is B: To administer antineoplastic chemotherapy. This is because antineoplastic chemotherapy agents are highly irritating and toxic to the surrounding tissues. Using midline and mid clavicular sites for IV therapy in this case can increase the risk of extravasation, leading to tissue damage and potential complications.
Incorrect choices:
A: To administer solutions with a pH greater than 5 and less than 9 - pH of the solution does not directly affect the choice of site for IV therapy.
C: To administer slow, low-volume infusions - Midline and mid clavicular sites can be appropriate for slow, low-volume infusions.
D: To administer high-pressure bolus injections - While midline and mid clavicular sites may not be ideal for high-pressure bolus injections, the question specifically mentions IV therapy, not bolus injections.
A patient is diagnosed with acute bacterial conjunctivitis. In providing patient teaching the nurse would tell the patient that this condition is more commonly known as which of the following?
- A. Glaucoma
- B. Color blindness
- C. Astigmatism
- D. Pinkeye
Correct Answer: D
Rationale: The correct answer is D: Pinkeye. Acute bacterial conjunctivitis is commonly referred to as "pinkeye" due to the characteristic pink or red appearance of the eye. This condition is caused by a bacterial infection of the conjunctiva, the thin membrane that covers the white part of the eye and inner eyelids. The term "glaucoma" (A) refers to a different eye condition characterized by increased intraocular pressure, while "color blindness" (B) is a genetic condition affecting color vision. "Astigmatism" (C) is a refractive error related to the shape of the cornea or lens, not an infection of the eye. Therefore, the correct answer is D as it accurately identifies the common name for acute bacterial conjunctivitis.
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. First, the nurse needs to assess the severity of the latex allergy to determine the appropriate interventions. Understanding the type of reaction can help guide treatment and prevent future exposure. Isolating the patient (choice A) is not necessary unless there is a severe reaction. Terminating the interview (choice C) prematurely is not appropriate as crucial information may be missed. Documenting the allergy (choice D) is important but not as urgent as assessing the reaction type.
The nurse will monitor J.E. for the following signs and symptoms:
- A. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
- B. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
- C. Loss of consciousness, bradycardia, petechiae, and severe leg pain
- D. Change in leve! of consciousness, bradycardia, chest pain and oliguria
Correct Answer: A
Rationale: The correct answer is A because signs and symptoms listed are indicative of disseminated intravascular coagulation (DIC), which is a serious condition where blood clotting and bleeding occur simultaneously. Change in level of consciousness can indicate hypoperfusion from clotting in blood vessels. Tachypnea and tachycardia can result from tissue hypoxia. Petechiae are small red or purple spots on the skin due to bleeding under the skin.
Choices B, C, and D are incorrect because they do not align with the typical signs and symptoms of DIC. Choice B suggests a possible myocardial infarction or acute coronary syndrome. Choice C indicates a possible thrombotic thrombocytopenic purpura (TTP) or acute limb ischemia. Choice D suggests a mix of symptoms that do not typically present together in DIC.