Nokea
The nurse is caring for a client who has just undergone a parathyroidectomy. Which of the following complications should the nurse monitor for in the immediate postoperative period?
- A. Hypocalcemia.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Hypocalcemia is a potential complication post-parathyroidectomy due to reduced parathyroid hormone production.
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The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which statement indicates understanding?
- A. I should eat large meals to avoid snacking.'
- B. I will sleep flat to relax my stomach.'
- C. I'll avoid lying down for 2 hours after eating.'
- D. I can drink orange juice with breakfast.'
Correct Answer: C
Rationale: Avoiding lying down for 2 hours after eating prevents acid reflux by keeping the stomach contents below the esophagus.
A nurse is relieving the triage nurse in the labor and delivery unit who is going to lunch. The report indicates that there are three clients having their vital signs assessed and a fourth client is on her way to the unit from the emergency department. In which order of priority should the nurse manage these clients?
- A. The client with clear vesicles and brown vaginal discharge at 16 weeks' gestation.
- B. The client with right lower quadrant pain at 10 weeks' gestation.
- C. The client who is at term and has had no fetal movement for 2 days.
- D. The client from the emergency department at term and screaming loudly because of labor contractions.
Correct Answer: C,D,A,B
Rationale: The client with no fetal movement at term is the highest priority due to the risk of fetal distress. The client in active labor requires immediate attention. Vesicles and discharge suggest possible infection, and right lower quadrant pain may indicate ectopic pregnancy, both serious but less urgent.
When performing chest percussion on a child, which of the following techniques should the nurse use?
- A. Firmly but gently striking the chest wall to make a popping sound.
- B. Gently striking the chest wall to make a slapping sound.
- C. Percussing over an area from the umbilicus to the clavicle.
- D. Placing a blanket between the nurse's hand and the child's chest.
Correct Answer: A
Rationale: Chest percussion involves firmly but gently striking the chest to produce a popping sound, mobilizing secretions without causing harm.
A client with a diagnosis of schizophrenia is prescribed aripiprazole (Abilify). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Hypotension.
- C. Dry mouth.
- D. Akathisia.
Correct Answer: A,D
Rationale: Aripiprazole can cause weight gain and akathisia (restlessness), which the nurse should monitor.
A client with type 1 diabetes mellitus is admitted with symptoms of hyperglycemia. Which laboratory finding should the nurse expect?
- A. Blood glucose of 90 mg/dL.
- B. Serum pH of 7.45.
- C. Ketones present in urine.
- D. Serum potassium of 5.5 mEq/L.
Correct Answer: C
Rationale: Hyperglycemia in type 1 diabetes often leads to diabetic ketoacidosis, with ketones in the urine due to fat metabolism, a key finding to monitor.