Nokea
The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately?
- A. Elevated blood pressure
- B. Heart rate irregularity
- C. Low oxygen saturation
- D. Noisy breathing
Correct Answer: D
Rationale: Noisy breathing post-thyroidectomy may indicate airway obstruction from hematoma or edema, a life-threatening emergency. Other findings are less immediately critical but still require monitoring.
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A client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client?
- A. A private room with contact and droplet precautions
- B. A private room with negative airflow and contact and airborne precautions
- C. A private room with positive airflow and airborne precautions
- D. A semi-private 2-bed room with standard precautions
Correct Answer: B
Rationale: Disseminated shingles in immunocompromised clients requires contact and airborne precautions due to varicella-zoster virus transmission risk. A private room with negative airflow prevents spread. Droplet or standard precautions are insufficient, and positive airflow is inappropriate.
Prior to discharge from the postanesthesia care unit following a vein stripping of the left leg, the nurse should tell the client to:
- A. apply heat to the affected leg for 10 minutes out of every hour for the next 24 hours.
- B. sit with the legs up or walk but avoid prolonged standing and sitting with the feet down.
- C. avoid weight bearing on the affected leg for the next week.
- D. remove the compression bandages after 24 hours.
Correct Answer: B
Rationale: Elevating legs or walking promotes venous return, while avoiding prolonged standing/sitting prevents stasis post-vein stripping. Heat, non-weight bearing, and early bandage removal are not recommended.
The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse
- A. attaches the drainage tubing to a leg collection bag
- B. retracts the foreskin before applying the condom sheath
- C. assesses the condition of the penile skin prior to application
- D. leaves a 1- to 2-inch (2.5- to 5-cm) space at the tip of the condom
Correct Answer: B
Rationale: Retracting the foreskin before applying a condom catheter risks paraphimosis if not repositioned afterward, requiring intervention. Other actions are correct: attaching tubing, assessing skin, and leaving space prevent complications.
The nurse is caring for a man who had a transsphenoidal hypophysectomy earlier today. He says he has to spit a lot. What nursing action is essential?
- A. Ask him to blow his nose.
- B. Do a glucose test on his mouth secretions.
- C. Have him rinse his mouth with water.
- D. Ask him if he needs an antiemetic.
Correct Answer: B
Rationale: Excessive spitting may indicate cerebrospinal fluid (CSF) leak, which contains glucose; testing secretions confirms this serious complication.
A client returns from surgery after having a suprapubic prostatectomy. Upon assessing the client, the nurse notes that his urine is bright red with many clots. Which of the following nursing actions is most appropriate?
- A. Check the client's vital signs and notify the physician.
- B. Check whether the continuous irrigation is working properly.
- C. Recognize that this is a normal finding after surgery and continue post-op care.
- D. Apply traction on the catheter and notify the physician.
Correct Answer: B
Rationale: Bright red urine with clots suggests a need to check the continuous bladder irrigation system to ensure it is functioning to prevent clot obstruction.