Nokea
To detect complications of surgery in the immediate postoperative period, which assessment component is most important for the nurse to monitor?
- A. Blood pressure
- B. Urine output
- C. Upperness
- D. Specific gravity
Correct Answer: A
Rationale: Blood pressure monitoring detects adrenal insufficiency or bleeding post-adrenalectomy.
You may also like to solve these questions
The nursing assistant reports to the nurse that the client's blood glucose reading is 58 mg/dL. What is the most appropriate nursing action at this time?
- A. The nurse is the need to be a condition.
- B. Give the client 1/4 cup of sweet fruit juice.
- C. Report the client's symptoms to the physician.
- D. Perform a complete head-to-toe assessment.
Correct Answer: B
Rationale: A blood glucose of 58 mg/dL with symptoms indicates hypoglycemia, requiring immediate administration of a fast-acting carbohydrate like fruit juice.
The client is diagnosed with hypothyroidism. Which assessment data support this diagnosis?
- A. The client's vital signs are: T 99.0, P 110, R 26, and BP 145/80.
- B. The client complains of constipation and being constantly cold.
- C. The client has an intake of 780 mL and output of 256 mL.
- D. The client complains of a headache and has projectile vomiting.
Correct Answer: B
Rationale: Constipation and cold intolerance are classic hypothyroidism symptoms due to slowed metabolism. Tachycardia/hypertension, fluid imbalance, and vomiting are unrelated.
The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test?
- A. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours.
- B. The client will be administered an injection of antidiuretic hormone (ADH), and urine output will be measured for four (4) to six (6) hours.
- C. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until the end of the test.
- D. An IV will be started with normal saline, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done.
Correct Answer: C
Rationale: The fluid deprivation test involves NPO status with hourly vitals and weights to assess urine concentration, diagnosing DI. Other options describe incorrect procedures.
The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes?
- A. Eat a simple carbohydrate snack before exercising.
- B. Carry peanut butter crackers when exercising.
- C. Encourage the client to walk 20 minutes three (3) times a week.
- D. Perform warm-up and cool-down exercises.
Correct Answer: D
Rationale: Warm-up and cool-down exercises prevent injury during exercise, crucial for type 2 diabetics. Pre-exercise snacks are for insulin users, peanut butter is high-fat, and walking is good but not the focus.
The client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client?
- A. Instruct the client to take the glucocorticoid and mineralocorticoid medications as prescribed.
- B. Teach the client regarding sexual functioning and androgen replacement therapy.
- C. Explain the signs and symptoms of infection and when to call the health-care provider.
- D. Demonstrate turn, cough, and deep-breathing exercises the client should perform every two (2) hours.
Correct Answer: C
Rationale: Infection signs are critical post-adrenalectomy due to immunosuppression risks. Steroid replacement is for bilateral procedures, androgen therapy is rare, and breathing exercises are inpatient-focused.