Nokea
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Calcium level of 8.0 mg/dL.
- B. Temperature of 99.5°F (37.5°C).
- C. Heart rate of 100 bpm.
- D. Pain at the incision site.
Correct Answer: A
Rationale: A calcium level of 8.0 mg/dL indicates hypocalcemia, a serious complication post-thyroidectomy due to parathyroid damage, risking tetany or seizures. Options B, C, and D are expected: slight fever, tachycardia, and incision pain are common postoperatively.
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A nurse is performing the routine daily cleaning of a tracheostomy. During the procedure, the client coughs and displaces the tracheostomy tube. This negative outcome could have been avoided by
- A. placing an obturator at the client's bedside
- B. having another nurse assist with the procedure
- C. fastening clean tracheostomy ties before removing old ties
- D. placing the client in a flat, supine position
Correct Answer: C
Rationale: fastening clean tracheostomy ties before removing old ties. Fastening clean tracheostomy ties before removing old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is coughed out. A second nurse is not needed. Changing the position may not prevent a dislodged tracheostomy.
A client is admitted to the emergency room in severe emotional distress. The client's respirations are 42/min, and the blood gases reveal a pH of 7.5 and a PaCO2 of 34.
Initially the nurse should
- A. instruct the client to breathe into a paper bag.
- B. start an IV of D5W.
- C. administer O2.
- D. have the client place his head between his knees.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-because of hyperventilation, client is in alkalosis; having him rebreathe his own carbon dioxide will reverse his blood gas imbalance (2) does not address the problem (3) is not hypoxic (4) is done when a client feels faint
A client admitted for regulation of her insulin dosage. The client takes 15 units of Humulin N insulin at 8 AM every day.
At 4 PM, which of the following nursing observations would indicate a complication from the insulin?
- A. Acetone odor to the breath, polyuria, and flushed skin.
- B. Irritability, tachycardia, and diaphoresis.
- C. Headache, nervousness, and polydipsia.
- D. Tenseness, tachycardia, and anorexia.
Correct Answer: B
Rationale: Strategy: Determine the cause of each symptom and how it relates to hypoglycemia. (1) signs of hyperglycemia (2) correct-Humulin N insulin is an intermediate-acting insulin that peaks from eight to twelve hours after administration; this is when signs and symptoms of hypoglycemia will occur (3) signs of hyperglycemia (4) signs of hyperglycemia
A terminally ill client says to the nurse, 'Do you believe in heaven?' How should the nurse respond?
- A. Yes, I believe in heaven and hell.'
- B. My personal belief is private.'
- C. Do you believe in heaven?'
- D. Do you want to see your clergyman?'
Correct Answer: C
Rationale: Reflecting the question back encourages the client to share beliefs, fostering spiritual discussion. Sharing personal beliefs, withholding, or redirecting are less therapeutic.
The nurse is caring for a client who is suffering from severe anxiety. What must the client do first when learning to deal with his anxiety?
- A. Recognize that he is feeling anxious
- B. Identify the situations that precipitated his anxiety
- C. Understand the reason for his anxiety
- D. Select a strategy to use to help him cope with his anxiety
Correct Answer: A
Rationale: Recognizing anxiety is the first step in managing it, enabling the client to address triggers, reasons, and coping strategies sequentially.