Nokea
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Heart rate of 80 bpm.
- D. Calcium level of 9.0 mg/dL.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-thyroidectomy complication. Options A, C, and D are normal or expected.
You may also like to solve these questions
A client with MRSA is receiving Vanomycin (Vancocin) IV. If the client experiences 'red man' syndrome, the nurse should:
- A. Slow the infusion and monitor the blood pressure.
- B. Check the client for signs of infection.
- C. Discontinue the medication and document the action.
- D. Continue the infusion because this is a normal reaction.
Correct Answer: A
Rationale: Red man syndrome is caused by rapid vancomycin infusion, leading to histamine release. Slowing the infusion and monitoring blood pressure manage symptoms. It's not normal, and discontinuing is unnecessary.
An older man is being prepared for discharge after treatment for dehydration.
Which of the following statements, if made by the patient to the nurse, indicates that further teaching is needed?
- A. I should weigh myself daily.'
- B. I should drink fluids throughout the day.'
- C. I can use a measuring cup to find out how much I drink during the day.'
- D. I should let my doctor know if I get dizzy when I change positions.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to dehydration. Be careful, this is a negative question. (1) correct-would only indicate overhydration, not response to dehydration (2) will help prevent recurrence of dehydration, should force fluids to 3,000 cc/day (3) would give good indication of total intake (4) would indicate postural hypotension resulting from volume deficit
A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving aminophylline, 25 mg/hour. Which one of the following findings by the nurse would require immediate intervention?
- A. Decreased blood pressure and respirations
- B. Flushing and headache
- C. Restlessness and palpitations
- D. Increased heart rate and blood pressure
Correct Answer: C
Rationale: Restlessness and palpitations. Side effects of Aminophylline include restlessness and palpitations.
Which of the following should be included in the discharge teaching of a client with a unilateral adrenalectomy?
- A. The client's need to pay close attention to skin care
- B. The client's need to restrict dietary intake of sodium and protein
- C. The client's need to recognize signs of hypoglycemia
- D. The client's need for daily steroid medication
Correct Answer: D
Rationale: Unilateral adrenalectomy may impair cortisol production, requiring lifelong steroid replacement. Skin care, dietary restrictions, and hypoglycemia are not primary concerns.
The nurse is teaching a client with a new diagnosis of ulcerative colitis about mesalamine (Asacol). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any fever or sore throat
- C. Stop the medication if symptoms improve
- D. Avoid taking with meals
Correct Answer: B
Rationale: Fever or sore throat may indicate bone marrow suppression, a serious mesalamine side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication risks relapse, and it can be taken with meals.