Nokea
The nurse is caring for a client who is postoperative day 1 following a total knee replacement. Which of the following findings should the nurse report to the physician immediately?
- A. Pain at the surgical site rated 6/10.
- B. Swelling and warmth at the incision site.
- C. Urine output of 150 mL over 8 hours.
- D. Serosanguineous drainage on the dressing.
Correct Answer: B
Rationale: swelling and warmth may indicate infection or a deep vein thrombosis, which requires immediate attention
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The nurse is caring for a client receiving treatment for hypoparathyroidism. The nurse determines that treatment has been successful if which of the following was observed?
- A. The client's output is 1500 cc of clear straw-colored urine.
- B. The client is unable to state his name.
- C. The client denies numbness and tingling.
- D. The client loses 3 pounds in one week.
Correct Answer: C
Rationale: Hypoparathyroidism causes hypocalcemia, leading to numbness and tingling. Their absence indicates successful calcium therapy. Options A, B, and D are unrelated or indicate other issues.
A client is scheduled to have a parathyroidectomy. The nurse would be MOST concerned if the client was observed eating quantities of food from which of the following food groups?
- A. Milk products.
- B. Green vegetables.
- C. Seafood.
- D. Poultry products.
Correct Answer: A
Rationale: low-calcium diet is recommended preoperatively
An 8-year-old client is returned to the recovery room after a bronchoscopy.
- A. How should the nurse position an 8-year-old client after a bronchoscopy?
- B. In semi-Fowler’s position.
- C. Prone, with the head turned to the side.
- D. With the head of the bed elevated 45° and the neck extended.
- E. Supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position promotes lung expansion and reduces the risk of airway obstruction from edema or secretions post-bronchoscopy. Prone positioning limits respiratory assessment, neck extension risks airway obstruction, and supine does not optimize breathing.
A client is scheduled for a cardiac catheterization, and the nurse teaches him about the procedure. What statements, if made by the client, would indicate to the nurse that he understands the teaching?
- A. I'm going to feel cold during the procedure.
- B. I can get up and walk to the bathroom immediately after the procedure.
- C. The nurse will be checking my foot pulses after the procedure.
- D. I won't be able to eat for 24 hours before the procedure.
Correct Answer: C
Rationale: peripheral pulses checked every 15 min for 1 h, then every 30 min for 2 h, then every 4 h
The nurse is caring for a client with a nasogastric (NG) tube. Which of the following actions should the nurse take to ensure proper functioning of the NG tube?
- A. Irrigate the tube with 50 mL of sterile water every 4 hours.
- B. Check for residual volume every 8 hours.
- C. Secure the tube to the client's gown only.
- D. Keep the head of the bed flat at all times.
Correct Answer: B
Rationale: checking residual volume ensures the tube is functioning and prevents overfeeding or aspiration