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What is the best way to assess for hemorrhage in a client who has had a thyroidectomy?
- A. Check the pulse and blood pressure hourly.
- B. Roll the client to the side and check for evidence of bleeding.
- C. Ask the client if he/she feels blood trickling down the back of the throat.
- D. Place a hand under the client's neck and shoulders to feel bed linens.
Correct Answer: D
Rationale: Placing a hand under the neck and shoulders detects blood pooling under the incision, a common site for post-thyroidectomy hemorrhage.
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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.
The nurse is administering a pancreatic enzyme to the client diagnosed with chronic pancreatitis. Which statement best explains the rationale for administering this medication?
- A. It is an exogenous source of protease, amylase, and lipase.
- B. This enzyme increases the number of bowel movements.
- C. This medication breaks down in the stomach to help with digestion.
- D. Pancreatic enzymes help break down fat in the small intestine.
Correct Answer: A
Rationale: Pancreatic enzymes provide protease, amylase, and lipase to compensate for pancreatic insufficiency, aiding digestion. They don’t increase bowel movements or break down in the stomach.
The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication?
- A. When is the last time you took your insulin?
- B. When did you have your last meal?
- C. Have you had some type of infection lately?
- D. How long have you had diabetes?
Correct Answer: C
Rationale: Infections are a common trigger for HHNS, precipitating hyperglycemia. Insulin timing, meal timing, and diabetes duration are less directly causative.
Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU?
- A. Glucose.
- B. Potassium.
- C. Calcium.
- D. Sodium.
Correct Answer: B
Rationale: DKA causes potassium depletion due to acidosis and diuresis; replacement is anticipated to prevent arrhythmias. Glucose is not an electrolyte, and calcium/sodium are less critical.
Which intervention is most appropriate to add to the client's care plan to the use of the personal bleeding after a subtotal thyroidectomy?
- A. Observe for signs of hypovolemic shock.
- B. Assess for dampness at the back of the client's neck.
- C. Remove the dressing to directly inspect the wound.
- D. Weigh all gauze dressings before and after changing.
Correct Answer: B
Rationale: Assessing for dampness at the back of the neck detects bleeding that may pool behind the client.