Nokea
The nurse is caring for a client who is postoperative day 1 after a mastectomy. Which of the following actions is the PRIORITY?
- A. Encourage the client to perform arm exercises.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Encouraging arm exercises is the priority to prevent lymphedema and restore mobility post-mastectomy. Options B, C, and D are important but secondary: pain management, drain monitoring, and incision checks follow mobility promotion.
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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.
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I have muscle cramps.
- D. I take my medication with food.
Correct Answer: C
Rationale: Muscle cramps suggest hyperkalemia, a serious side effect of spironolactone, a potassium-sparing diuretic, requiring immediate evaluation to prevent arrhythmias. Options A, B, and D are less concerning: fatigue and dry mouth are nonspecific, and taking with food is acceptable.
An adult is admitted to the unit with a fractured femur and will be in Buck's extension traction for several days. The client tells the nurse that she has all of the following. Which is likely to cause the client the most problems at this time?
- A. High blood pressure
- B. Hiatal hernia
- C. Osteoarthritis of the fingers
- D. High cholesterol
Correct Answer: B
Rationale: Hiatal hernia can be exacerbated by prolonged immobility in traction, increasing reflux and discomfort. Hypertension, finger osteoarthritis, and high cholesterol are less directly impacted by traction.
A client is receiving a nitroglycerin infusion for unstable angina. What assessment would be a priority when monitoring the effects of this medication?
- A. Blood pressure
- B. Cardiac enzymes
- C. ECG analysis
- D. Respiratory rate
Correct Answer: A
Rationale: Since an effect of this drug is vasodilation, the client must be monitored for hypotension.
According to Erickson's stage of growth and development, the developmental task associated with middle childhood is:
- A. Trust
- B. Initiative
- C. Independence
- D. Industry
Correct Answer: D
Rationale: Middle childhood (ages 6-12) is associated with the developmental task of industry, where children focus on competence and achievement.