• The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert
... [Show More] for:
A. Nasal congestion
B. Abdominal tenderness
C. Muscle tetany
D. Oliguria
Answer A: Removal of the pituitary gland is usually done by a transsphenoidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland.
• A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis
Answer B: Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits, making answers A, C, and D
incorrect.
• A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse?
A. Taking the vital signs
B. Obtaining the permit
C. Explaining the procedure
D. Checking the lab work
Answer A: The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.
• The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority?
A. Starting an IV
B. Applying oxygen
C. Obtaining blood gases
D. Medicating the client for pain
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
• The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet?
A. Roasted chicken
B. Noodles
C. Cooked broccoli
D. Custard
Answer C: The client with diverticulitis should avoid eating foods that are
gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed.
• The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:
A. The baby is dehydrated due to polyuria.
B. The baby is hypoglycemic due to lack of glucose.
C. The baby is allergic to the formula the mother is giving him.
D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breast-feeding.
Answer D: After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula; thus, answers A, B, and C are incorrect.
• The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis?
A. Foul breath
B. Dysphagia
C. Diarrhea
D. Chronic hiccups
Answer C: Diarrhea is not common in clients with mouth and throat cancer. All the findings in answers A, B, and D are expected findings.
• A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan?
A. Closed chest drainage
B. A tracheostomy
C. A mediastinal tube
D. Percussion vibration and drainage
Answer A: The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect. [Show Less]