CORRECT SOLUTIONS A+
1. Question1 point(s)
Category: Management of Care
The nurse is managing care for several clients in the outpatient clinic. Among the
following clients who called, which one should the nurse prioritize in responding
to first?
A. A client with hepatitis A who states, “My arms and legs are itching.”
B. A client with a cast on the right leg who states, “I have a funny feeling in my
right leg.”
Correct
C. A client with osteomyelitis of the spine who states, “I am so nauseous that I
can’t eat.”
D. A client with rheumatoid arthritis who states, “I am having trouble sleeping.”
Correct
,Correct Answer: E. A client with a cast on the right leg who states, “I have a funny
feeling in my right leg.”
It may indicate neurovascular compromise, requiring immediate assessment.
Option A: Bilirubin levels in hepatitis A may increase, and itching is a common
symptom.
Option C: A client feeling nauseous may require consultation but is not a priority.
Option D: Clients with rheumatoid arthritis may feel pain in the affected areas at
night. They may need a prescription for painkillers but it is not urgent.
2. Question1 point(s)
Category: Management of Care
A nurse on the surgical floor is prioritizing care for clients after receiving the
report from the previous shift. Which of the following patients should the nurse
assess first?
A. A 35-year-old patient admitted three hours ago for a gunshot wound, with a
1.5 cm area of dark drainage noted on the dressing.
B. A 43-year-old patient who underwent a mastectomy two days ago, with 23 ml
of serosanguinous fluid in the Jackson-Pratt drain.
,C. A 59-year-old patient with a history of a collapsed lung from an accident, with
no drainage noted in the chest tube in the past eight hours.
E. A 54-year-old patient with a total knee replacement two days ago, with
moderate swelling at the surgical site.
Incorrect
E. A 47-year-old patient who had a laparoscopic cholecystectomy yesterday,
complaining of mild pain at the incision site.
F. A 62-year-old patient who had an abdominal-perineal resection three days
ago, now reporting chills.
Correct Answer
Incorrect
Correct Answer: F. A 62-year-old patient who had an abdominal-perineal
resection three days ago, now reporting chills.
The client is at risk for peritonitis; should be assessed for further symptoms and
infection.
3. Question1 point(s)
Category: Physiological Adaptation
, A nurse in a post-surgical unit is monitoring a 46-year-old patient who underwent
a thyroidectomy 12 hours ago for the treatment of Grave’s disease. Which of the
following observations should most concern the nurse?
A. Blood pressure 138/82 mmHg, respirations 16 per minute, oral temperature
37.2ºC or 99º F.
B. The patient carefully supports their head and neck when turning their head to
the right.
C. The patient expresses difficulty in swallowing but can manage liquids.
D. The patient appears drowsy and complains of a sore throat.
E. The patient shows involuntary flexion of their wrist when blood pressure is
measured.
Correct Answer
F. The patient has a hoarse voice when speaking.
Incorrect
Incorrect
Correct Answer: E. The patient shows involuntary flexion of their wrist when
blood pressure is measured.
Carpal spasms (Trousseau’s sign) indicate hypocalcemia which can occur after
thyroidectomy due to accidental removal or damage to the parathyroid glands.