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Questions 158

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Question 1 of 5

The nurse is preparing to receive a client from admitting with tumor lysis syndrome (TLS). Which of the following would the nurse expect to find on the laboratory and patient history sections of the chart?

Correct Answer: A,C,D,E

Rationale: TLS causes hyperkalemia (
C), hyperuricemia (
D), and mental changes (E) due to electrolyte imbalances and low blood pressure (
A) from fluid shifts. Hyperactivity (
B) is not typical.

Question 2 of 5

A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?

Correct Answer: C

Rationale: Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous.

Question 3 of 5

Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:

Correct Answer: A

Rationale: Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. Range of motion exercises are not appropriate to presenting symptoms. These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. Phenytoin is indicated for seizure activity mainly of neurological origin.

Question 4 of 5

A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, 'Oh dear, I feel like I have to urinate again!' Which of the following is the most appropriate initial nursing response?

Correct Answer: B

Rationale: The most frequent reason for an urge to void with an indwelling catheter is blocked tubing, so checking the catheter's patency is the best initial response.

Question 5 of 5

A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:

Correct Answer: B

Rationale: Dressing in extra layers is a safe, effective way to manage cold intolerance in hypothyroidism by conserving body heat. Electric blankets and heating pads pose burn risks, and baths are temporary.

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