Nokea
The nurse is caring for a client who is 2 days postoperative after a cholecystectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 99.5°F (37.5°C).
- B. Pain at the incision site.
- C. Yellowish drainage from the incision.
- D. Urine output of 1500 mL in 24 hours.
Correct Answer: C
Rationale: Yellowish drainage from the incision suggests infection or bile leakage, a serious complication post-cholecystectomy requiring immediate evaluation. Options A, B, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.
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Included in teaching the client with tuberculosis taking isoniazid (INH) about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
- A. Liver function
- B. Kidney function
- C. Blood sugar
- D. Cardiac enzymes
Correct Answer: A
Rationale: Liver function. INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.
An 85-year-old client with diverticulitis has been vomiting and febrile for 12 hours. Where is the best location to assess skin turgor on this client?
- A. Dorsal hand
- B. Feet
- C. Back of the arm
- D. Sternum
Correct Answer: D
Rationale: This is the best area to check in the elderly due to loss of skin elasticity that occurs with aging. Answers A, B, and C are all influenced by loss of elasticity more than the sternum, so they are incorrect.
The nurse is caring for a client with a history of polycystic kidney disease.
- A. Which symptom is expected in a client with polycystic kidney disease?
- B. Chest pain and dyspnea.
- C. Flank pain and hematuria.
- D. Weight loss and fever.
- E. Numbness in the extremities.
Correct Answer: B
Rationale: Flank pain and hematuria are common in polycystic kidney disease due to cyst pressure and rupture. Chest pain, weight loss, and numbness are unrelated.
A 21-year-old primipara in active labor.
The nurse observes a new graduate nurse palpating the uterine contractions of a 21-year-old primipara in active labor. Which of the following actions, if taken by the new graduate nurse, is MOST appropriate?
- A. The graduate nurse places the palm of one hand on the fundus and moves the hand around the abdomen.
- B. The graduate nurse places the heels of both hands on the lower abdomen and presses lightly.
- C. The graduate nurse places one hand on the abdomen over the fundus and with the fingertips, presses gently.
- D. The graduate nurse places the palms of the hands on either side of the abdomen and presses firmly.
Correct Answer: C
Rationale: Strategy: 'MOST appropriate' indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) palpations should be done with fingertips, not palms of hands (2) palpations should be done with fingertips, not heels of hands (3) correct-done with fingertips (4) palpations should be done with fingertips, not palms of hands
The nurse is teaching a client with a new diagnosis of hypothyroidism about levothyroxine (Synthroid). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime
- B. Report any chest pain
- C. Stop the medication if symptoms improve
- D. Avoid taking with calcium supplements
Correct Answer: B
Rationale: Chest pain may indicate overstimulation from levothyroxine, mimicking hyperthyroidism. Options A, C, and D are incorrect: morning dosing is preferred, stopping the medication risks relapse, and calcium supplements should be avoided but are secondary.