Nokea
The nurse is reviewing the chart of a 55-year-old male client who is scheduled for a lumbar laminectomy. The nurse should report which of the following to the surgeon?
- A. Pimple on the lower back.
- B. Abnormal electrocardiogram (ECG).
- C. Hearing aid.
- D. Allergy to iodine.
Correct Answer: B
Rationale: An abnormal ECG indicates potential cardiac issues that could affect surgical safety under anesthesia. This must be reported to the surgeon for further evaluation. A pimple, hearing aid, or iodine allergy, while notable, are less immediately critical unless directly related to the procedure.
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Which medication is prescribed to prevent uric acid stones?
- A. Hydrochlorothiazide.
- B. Allopurinol.
- C. Potassium citrate.
- D. Acetaminophen.
Correct Answer: B
Rationale: Allopurinol reduces uric acid levels, preventing stone formation.
Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy?
- A. Pains in the joints of the hands and feet.
- B. Tingling in the fingers.
- C. Bleeding on the back of the dressing.
- D. Tension on the suture line.
Correct Answer: B
Rationale: Tetany, caused by hypocalcemia from parathyroid gland damage during thyroidectomy, presents with tingling in the fingers, muscle cramps, or spasms.
The nurse should instruct the client with an ileostomy to report which of the following signs and symptoms immediately?
- A. Passage of liquid stool from the stoma.
- B. Occasional presence of undigested food in the effluent.
- C. Absence of drainage from the ileostomy for 6 or more hours.
- D. Temperature of 99.8°F (37.7°C).
Correct Answer: C
Rationale: Absence of drainage from an ileostomy for 6 or more hours may indicate a blockage, requiring immediate reporting. Liquid stool and undigested food are normal, and a slightly elevated temperature is less urgent unless persistent. CN: Physiological adaptation; CL: Synthesize
A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for:
- A. Vertigo.
- B. Facial paralysis.
- C. Impaired vision.
- D. Difficulty swallowing.
Correct Answer: A
Rationale: Streptomycin can damage the eighth cranial nerve (vestibulocochlear), causing vertigo or hearing loss. Facial paralysis, impaired vision, and difficulty swallowing are associated with other cranial nerves.
Which pediatric surgery client should not play with a balloon?
- A. A child having her 15th laser surgery for a hemangioma.
- B. A child having a tonsillectomy.
- C. A child having an inguinal hernia repair.
- D. A child having an orchiopexy.
Correct Answer: B
Rationale: A child post-tonsillectomy should avoid balloons, as blowing or playing with them can increase intraoral pressure, risking bleeding or disruption of the surgical site.