Nokea
Which client problem is the nurse’s priority concern for the client diagnosed with acute pancreatitis?
- A. Impaired nutrition.
- B. Skin integrity
- C. Anxiety
- D. Pain relief.
Correct Answer: D
Rationale: Acute pancreatitis is characterized by severe abdominal pain due to pancreatic inflammation and autodigestion. Pain relief is the priority concern, as it addresses the client’s immediate discomfort, improves patient comfort, and reduces physiological stress, which can exacerbate the condition. Using the ABCs (Airway, Breathing, Circulation) and Maslow’s hierarchy, pain is a physiological need that takes precedence. Impaired nutrition (1) is relevant but secondary, as clients are often NPO initially. Skin integrity (2) and anxiety (3) are lower priorities, as they are less immediate concerns in acute pancreatitis.
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To prepare for potential postoperative complications related to the thyroidectomy, which item is necessary to keep at the client's bedside?
- A. Dressing change kit
- B. Tracheostomy tray
- C. Ampule of epinephrine
- D. Mechanical ventilator
Correct Answer: B
Rationale: A tracheostomy tray is essential in case of airway obstruction due to swelling or hematoma post-thyroidectomy.
Which sign/symptom should the nurse expect in the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)?
- A. Excessive thirst.
- B. Orthopnea.
- C. Ascites.
- D. Concentrated urine output.
Correct Answer: D
Rationale: SIADH causes excessive ADH, leading to water retention, hyponatremia, and concentrated urine output due to reduced urine volume. Excessive thirst is typical of diabetes insipidus, orthopnea relates to heart failure, and ascites is linked to liver disease.
The client with DM is to receive insulin IV at 1.5 units per hour. The insulin bag contains 10 units of insulin in 100 mL of NS. The nurse should set the infusion pump to deliver how many milliliters per hour?
- A. 1.0 mL/hr
- B. 1.5 mL/hr
- C. 2.0 mL/hr
- D. 2.5 mL/hr
Correct Answer: B
Rationale: 10 units : 100 mL :: 1.5 units : X mL; 10X = 150; X = 1.5 mL/hr.
The nurse should assess for hypocalcemia based on which client statements after a subtotal thyroidectomy?
- A. I feel tingling in my hands and feet.
- B. I have a headache.
- C. I feel sleepy.
- D. I have a sore throat.
Correct Answer: A
Rationale: Tingling in the hands and feet indicates hypocalcemia, a potential complication due to parathyroid gland damage during thyroidectomy.
The nurse is interviewing four clients. Which client is at the greatest risk for developing type 2 DM?
- A. 56-year-old Hispanic female
- B. 40-year-old Asian American female
- C. 25-year-old obese Caucasian male
- D. 38-year-old Native American male
Correct Answer: D
Rationale: Research has shown that the highest incidence of DM is among Native Americans.