The nurse is caring for a postoperative parathyroidectomy client. Which client
complaint would indicate that a life-threatening complication may be developing,
requiring notification of the health care provider immediately?
A. Abdominal cramps
B. Difficulty in voiding
C. Mild to moderate incisional pain
D. Laryngeal stridor
Give this one a try later!
, ANS: D
During the postoperative period, the nurse carefully observes the client for
signs of hemorrhage, which causes swelling and compression of adjacent
tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration
and expiration; stridor is caused by compression of the trachea, leading to
respiratory distress. Stridor is an acute emergency situation that requires
immediate attention to avoid complete obstruction of the airway. The other
answers do not identify signs of a life-threatening complication.
To prevent and treat atelectasis the nurse would intervene with all of the following,
except:
A. Deep breathing exercises
B. Early mobility
C. Incentive Spirometry
D. Allow patient to stay bedridden
Give this one a try later!
ANS: D
Prevention and treatment of atelectasis include: deep breathing exercises,
incentive spirometry and early mobility. Allowing a patient to stay
bedridden is placing them at risk for atelectasis.
A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On
assessment, which manifestation related to the client's menstrual cycle would the
nurse expect the client to report?
A. Menorrhagia
B. Metrorrhagia
C. Amenorrhea
D. Dysmenorrhea
Give this one a try later!
, ANS: C
Amenorrhea or a decreased menstrual flow is common in the client with
Graves' disease. Menorrhagia, metrorrhagia, and dysmenorrhea are also
disorders related to the female reproductive system; however, they do not
manifest in the presence of Graves' disease. Menorrhagia refers to
menstrual periods with abnormally heavy or prolonged bleeding.
Metorrhagia refers to uterine bleeding at irregular intervals, particularly
between the expected menstrual periods. Dysmenorrhea refers to pain
during menstrual periods.
The evening nurse reviews the nursing documentation in a client's chart and notes that
the day nurse has documented that the client has a stage II pressure ulcer in the
sacral area. Which finding would the nurse expect to note on assessment of the
client's sacral area?
A. Partial-thickness skin loss of the dermis
B. Exposed bone, tendon, or muscle
C. Full-thickness skin loss
D. Intact skin
Give this one a try later!
ANS: A
Stage 2 pressure ulcers are characterized by partial-thickness skin loss into
but no deeper than the dermis. This includes intact or ruptured blisters.
Which patients have the greatest risk for aspiration pneumonia? (select all that apply)
A. Patient who is receiving nasogastric tube feeding
B. Patient with seizures
C. Patient who had a myocardial infarction
D. Patient with a head injury
Give this one a try later!
, ANS: A, B, D
Aspiration pneumonia results from the abnormal entry of material from the
mouth or stomach into the trachea and lungs. Conditions that increase the
risk for aspiration include decreased level of consciousness (i.e. seizure,
anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and
insertion of nasogastric (NG) tubes with or without enteral feeding. With
loss of consciousness, the gag and cough reflexes are depressed and
aspiration is more likely to occur.
The nurse is conducting preoperative teaching with a client about the use of an
incentive spirometer. The nurse should include which piece of information in
discussions with the client?
A. Inhale as rapidly as possible
B. The best results are achieved when sitting up or with the head of the bed elevated
45 to 90 degrees
C. After maximum inspiration, hold the breath for 15 seconds and exhale
D. Keep a loose seal between the lips and the mouthpiece
Give this one a try later!
ANS: B
For optimal lung expansion with the incentive spirometer, the client should
assume the semi-Fowler's or high-Fowler's position. The mouthpiece should
be covered completely and tightly while the client inhales slowly, with a
constant flow through the unit. The breath should be held for 5 seconds
before exhaling slowly.
A client are risk for developing pressure ulcers complains to the nurse about the
turning schedule because the client does not rest well when placed in a side-lying
position. The nurse teaches the client which of the following to gain compliance?
A. "Turning prevents the breakdown of skin that could eventually cause infection."
B. "Heat loss from pressure areas is prevented when you are not turned."
C. "Pressure causes decreased absorption of Vitamin D."
D. "You will lose sensation in pressure areas if you are not turned."
complaint would indicate that a life-threatening complication may be developing,
requiring notification of the health care provider immediately?
A. Abdominal cramps
B. Difficulty in voiding
C. Mild to moderate incisional pain
D. Laryngeal stridor
Give this one a try later!
, ANS: D
During the postoperative period, the nurse carefully observes the client for
signs of hemorrhage, which causes swelling and compression of adjacent
tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration
and expiration; stridor is caused by compression of the trachea, leading to
respiratory distress. Stridor is an acute emergency situation that requires
immediate attention to avoid complete obstruction of the airway. The other
answers do not identify signs of a life-threatening complication.
To prevent and treat atelectasis the nurse would intervene with all of the following,
except:
A. Deep breathing exercises
B. Early mobility
C. Incentive Spirometry
D. Allow patient to stay bedridden
Give this one a try later!
ANS: D
Prevention and treatment of atelectasis include: deep breathing exercises,
incentive spirometry and early mobility. Allowing a patient to stay
bedridden is placing them at risk for atelectasis.
A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On
assessment, which manifestation related to the client's menstrual cycle would the
nurse expect the client to report?
A. Menorrhagia
B. Metrorrhagia
C. Amenorrhea
D. Dysmenorrhea
Give this one a try later!
, ANS: C
Amenorrhea or a decreased menstrual flow is common in the client with
Graves' disease. Menorrhagia, metrorrhagia, and dysmenorrhea are also
disorders related to the female reproductive system; however, they do not
manifest in the presence of Graves' disease. Menorrhagia refers to
menstrual periods with abnormally heavy or prolonged bleeding.
Metorrhagia refers to uterine bleeding at irregular intervals, particularly
between the expected menstrual periods. Dysmenorrhea refers to pain
during menstrual periods.
The evening nurse reviews the nursing documentation in a client's chart and notes that
the day nurse has documented that the client has a stage II pressure ulcer in the
sacral area. Which finding would the nurse expect to note on assessment of the
client's sacral area?
A. Partial-thickness skin loss of the dermis
B. Exposed bone, tendon, or muscle
C. Full-thickness skin loss
D. Intact skin
Give this one a try later!
ANS: A
Stage 2 pressure ulcers are characterized by partial-thickness skin loss into
but no deeper than the dermis. This includes intact or ruptured blisters.
Which patients have the greatest risk for aspiration pneumonia? (select all that apply)
A. Patient who is receiving nasogastric tube feeding
B. Patient with seizures
C. Patient who had a myocardial infarction
D. Patient with a head injury
Give this one a try later!
, ANS: A, B, D
Aspiration pneumonia results from the abnormal entry of material from the
mouth or stomach into the trachea and lungs. Conditions that increase the
risk for aspiration include decreased level of consciousness (i.e. seizure,
anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and
insertion of nasogastric (NG) tubes with or without enteral feeding. With
loss of consciousness, the gag and cough reflexes are depressed and
aspiration is more likely to occur.
The nurse is conducting preoperative teaching with a client about the use of an
incentive spirometer. The nurse should include which piece of information in
discussions with the client?
A. Inhale as rapidly as possible
B. The best results are achieved when sitting up or with the head of the bed elevated
45 to 90 degrees
C. After maximum inspiration, hold the breath for 15 seconds and exhale
D. Keep a loose seal between the lips and the mouthpiece
Give this one a try later!
ANS: B
For optimal lung expansion with the incentive spirometer, the client should
assume the semi-Fowler's or high-Fowler's position. The mouthpiece should
be covered completely and tightly while the client inhales slowly, with a
constant flow through the unit. The breath should be held for 5 seconds
before exhaling slowly.
A client are risk for developing pressure ulcers complains to the nurse about the
turning schedule because the client does not rest well when placed in a side-lying
position. The nurse teaches the client which of the following to gain compliance?
A. "Turning prevents the breakdown of skin that could eventually cause infection."
B. "Heat loss from pressure areas is prevented when you are not turned."
C. "Pressure causes decreased absorption of Vitamin D."
D. "You will lose sensation in pressure areas if you are not turned."
