Nokea
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following actions is the PRIORITY?
- A. Monitor the client for neck swelling.
- B. Administer pain medication as needed.
- C. Encourage the client to cough and deep breathe.
- D. Check the incision for drainage.
Correct Answer: A
Rationale: Monitoring for neck swelling is the priority to detect hematoma, a life-threatening complication post-thyroidectomy that can cause airway obstruction. Options B, C, and D are important but secondary: pain management, respiratory exercises, and incision checks follow airway safety.
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An adult has received an injection of immunoglobulin. The client asks what this injection will do for him. The nurse's reply includes the information that he will develop which type of immunity as a result of this injection?
- A. Active natural immunity
- B. Active artificial immunity
- C. Passive natural immunity
- D. Passive artificial immunity
Correct Answer: D
Rationale: Immunoglobulin provides preformed antibodies, conferring passive artificial immunity. Active immunity requires the body to produce antibodies, and natural immunity involves natural exposure.
A client preparing for surgery.
Which of the following statements by the client BEST indicates to the nurse an emotional readiness for surgery?
- A. I know the doctor isn't telling me everything, but at this point I can't do anything about it.'
- B. I've never heard of this specialist before. Does he do much work here?'
- C. I'm glad the trapeze is on my bed so I can start working on my exercises as soon as I wake up.'
- D. Can you please check my record to be sure it says I'm diabetic?'
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) indicates feelings of fear and helplessness (2) indicates fear and lack of trust (3) correct-indicates acceptance and a readiness to participate in postoperative care (4) indicates fear that something will be missed
Omeprazole (Prilosec), cimetidine (Tagamet), and Maalox are ordered for an adult. When should the nurse plan to administer these drugs?
- A. Give omeprazole (Prilosec) before meals, cimetidine (Tagamet) with meals, and Maalox after meals.
- B. Give omeprazole (Prilosec) with meals, cimetidine (Tagamet) after meals, and Maalox before meals.
- C. Give omeprazole (Prilosec) after meals, cimetidine (Tagamet) before meals, and Maalox with meals.
- D. Give all of the drugs after meals.
Correct Answer: A
Rationale: Omeprazole (PPI) is taken before meals to inhibit acid production, cimetidine (H2 blocker) with meals to reduce acid during digestion, and Maalox (antacid) after meals to neutralize residual acid.
A client receiving tetracycline.
The nurse should include which of the following in a teaching plan for a client receiving tetracycline?
- A. Take the medication with milk or antacids to decrease GI problems.
- B. The medication should always be taken with meals.
- C. Use a maximum-protection sunscreen when outdoors.
- D. Crackers and juice will help decrease gastric irritation.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) tetracycline should never be taken with milk or antacids as these inhibit the medication's action (2) should take with full glass of water at least one hour before or two hours after meals (3) correct-because of problems related to photosensitivity, sunscreen, wide-brimmed hats, and long sleeves should be worn when client is at risk for sun exposure (4) should take with full glass of water at least one hour before or two hours after meals
The nurse is to obtain pedal pulses on a client following a cardiac catheterization. Which is the proper procedure?
- A. Place the fingertips against the wrist bone.
- B. Place the stethoscope over the apex of the heart.
- C. Place the fingertips against the side of the neck.
- D. Place the fingertips on top of the foot.
Correct Answer: D
Rationale: Pedal pulses are assessed by palpating the dorsalis pedis or posterior tibial arteries on the foot, checking for circulation post-catheterization.