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Questions 149

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Extract:


Question 1 of 5

On the second post-operative day after a subtotal thyroidectomy, the client tells the nurse, 'I feel numbness and my face is twitching.' What is the nurse's best initial action?

Correct Answer: C

Rationale: Numbness and facial twitching suggest hypocalcemia due to parathyroid gland damage during thyroidectomy, requiring immediate physician notification for calcium supplementation.

Question 2 of 5

The nurse is performing discharge instruction for a client with an implantable permanent pacemaker. What discharge instruction is an essential part of the plan?

Correct Answer: C

Rationale: Clients with pacemakers must monitor their pulse to ensure the device is functioning correctly and to detect irregularities, making pulse-taking an essential discharge instruction.

Question 3 of 5

The nurse has just received the shift report and is preparing to make rounds. Which client should be seen first?

Correct Answer: C

Rationale: The client with shortness of breath is at highest risk for respiratory distress and requires immediate assessment.

Question 4 of 5

The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300 mL. The nurse should give priority to:

Correct Answer: D

Rationale: A chest tube output of 300 mL per hour is excessive and may indicate hemorrhage, requiring immediate physician notification.

Question 5 of 5

A nurse is administering a blood transfusion to a client on the oncology unit. Which clinical manifestation indicates an acute hemolytic reaction to the blood?

Correct Answer: A

Rationale: Low back pain is a hallmark of acute hemolytic transfusion reaction due to hemolysis and kidney involvement. Fever, urticaria, or neck vein distention suggest other complications.

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