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Questions 164

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Question 1 of 5

The nurse is caring for a client who had a total thyroidectomy. What should the nurse plan to observe the client for immediately after his return to the nursing care unit?

Correct Answer: B

Rationale:
Total thyroidectomy risks parathyroid gland damage, leading to hypocalcemia (not hypercalcemia). However, the question likely intends hypocalcemia signs (tetany, spasms), which are critical to monitor immediately post-surgery. Hoarseness, reflexes, or confusion are less urgent.

Question 2 of 5

The licensed practical nurse is monitoring a client receiving an IV of Nipride in D5W. The IV bag has a foil covering, and the nurse notes that the IV fluid has a light brownish tint. The nurse should:

Correct Answer: D

Rationale: Nipride (nitroprusside) is light-sensitive and turns light brown, which is normal if protected by foil. No action is needed.

Question 3 of 5

An adult is admitted with Guillain-Barré syndrome. On day 3 of hospitalization, the client's muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in the nursing care plan at this time is to prevent which problem?

Correct Answer: A

Rationale: Difficulty swallowing increases aspiration risk, making aspiration pneumonia the priority. Other complications are secondary in this acute phase.

Question 4 of 5

The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the clients Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially?

Correct Answer: A

Rationale: The Foley bag must be kept below bladder level to prevent urine backflow and infection risk. Immediate correction and private education ensure safety and learning without delay.

Question 5 of 5

Which finding is commonly noted in the client with bladder cancer?

Correct Answer: A

Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often the earliest sign. Other symptoms may occur but are less specific.

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