Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
A. Muscle twitching
Muscle twitching can be indicative of hypocalcemia, a common and serious complication following a complete thyroidectomy due to potential damage or removal of the parathyroid glands. Hypocalcemia requires immediate intervention to prevent more severe symptoms such as tetany or cardiac complications.
B. Client report of nausea
While nausea is a common postoperative symptom, it is not typically as urgent as signs of hypocalcemia. However, persistent nausea should still be addressed as it can affect the client's comfort and nutritional intake.
C. Serosanguineous drainage
Serosanguineous drainage is expected to some extent after surgery, but if it is excessive or changes in character, it may indicate hemorrhage or infection, which would then become a priority.
D. Client report of incisional pain
Incisional pain is also expected postoperatively. While pain management is important for recovery, it is not as immediately concerning as potential hypocalcemia unless the pain is severe or uncontrolled, suggesting complications.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason : Muscle twitching can be indicative of hypocalcemia, a common and serious complication following a complete thyroidectomy due to potential damage or removal of the parathyroid glands. Hypocalcemia requires immediate intervention to prevent more severe symptoms such as tetany or cardiac complications.
Choice B reason : While nausea is a common postoperative symptom, it is not typically as urgent as signs of hypocalcemia. However, persistent nausea should still be addressed as it can affect the client's comfort and nutritional intake.
Choice C reason : Serosanguineous drainage is expected to some extent after surgery, but if it is excessive or changes in character, it may indicate hemorrhage or infection, which would then become a priority.
Choice D reason : Incisional pain is also expected postoperatively. While pain management is important for recovery, it is not as immediately concerning as potential hypocalcemia unless the pain is severe or uncontrolled, suggesting complications.
Similar Questions
A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hours. Which of the following actions should the nurse take?
A. Administer prescribed corticosteroids.
Administering corticosteroids is not the first-line action for dyspnea related to fluid overload or other causes of respiratory distress in this context.
B. Slow infusion rate and contact the provider.
Slowing the infusion rate is appropriate when there are signs of fluid overload, such as dyspnea and hypertension. Contacting the provider is crucial for further assessment and management, which may include diuretics or other interventions.
C. Lower the head of the bed to semi-Fowler's.
Lowering the head of the bed to semi-Fowler's may provide some relief for dyspnea, but it does not address the potential cause, which in this case could be fluid overload.
D. Change infusion to lactated Ringer's and maintain rate.
Changing the infusion to lactated Ringer's would not be appropriate if the client is experiencing symptoms of fluid overload. The type of fluid is less important than the volume and rate of administration in this scenario.
Full Explanation
Choice A reason : Administering corticosteroids is not the first-line action for dyspnea related to fluid overload or other causes of respiratory distress in this context.
Choice B reason : Slowing the infusion rate is appropriate when there are signs of fluid overload, such as dyspnea and hypertension. Contacting the provider is crucial for further assessment and management, which may include diuretics or other interventions.
Choice C reason : Lowering the head of the bed to semi-Fowler's may provide some relief for dyspnea, but it does not address the potential cause, which in this case could be fluid overload.
Choice D reason : Changing the infusion to lactated Ringer's would not be appropriate if the client is experiencing symptoms of fluid overload. The type of fluid is less important than the volume and rate of administration in this scenario.
A nurse is assessing a client who has heart failure and a new prescription for metoprolol. Which of the following findings should the nurse identify as an adverse effect of the medication?
A. Blood pressure 138/76 mm Hg
A blood pressure of 138/76 mm Hg is within the higher range of normal and is not typically considered an adverse effect of metoprolol, which is used to lower blood pressure.
B. Temperature 36.3°C (97.3°F)
A temperature of 36.3°C (97.3°F) is within the normal range and is not an adverse effect of metoprolol.
C. Heart rate 48/min
A heart rate of 48/min is considered bradycardia and can be an adverse effect of metoprolol, which is a beta-blocker that can slow down the heart rate.
D. Respiratory rate 10/min
A respiratory rate of 10/min is on the lower end of the normal range but is not a typical adverse effect of metoprolol. However, if the patient shows signs of respiratory distress, it should be addressed.
Full Explanation
Choice A reason : A blood pressure of 138/76 mm Hg is within the higher range of normal and is not typically considered an adverse effect of metoprolol, which is used to lower blood pressure.
Choice B reason : A temperature of 36.3°C (97.3°F) is within the normal range and is not an adverse effect of metoprolol.
Choice C reason : A heart rate of 48/min is considered bradycardia and can be an adverse effect of metoprolol, which is a beta-blocker that can slow down the heart rate.
Choice D reason : A respiratory rate of 10/min is on the lower end of the normal range but is not a typical adverse effect of metoprolol. However, if the patient shows signs of respiratory distress, it should be addressed.
A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?
A. Perform a Mantoux skin test on the client.
Choice A: Perform a Mantoux skin test on the client The Mantoux skin test is used to screen for tuberculosis, not pertussis. Pertussis, also known as whooping cough, is a bacterial infection caused by Bordetella pertussis. The Mantoux test would not be relevant or helpful in diagnosing or managing pertussis.
B. Assign the client to a negative-pressure airflow room.
Choice B: Assign the client to a negative-pressure airflow room Negative-pressure airflow rooms are typically used for airborne infections such as tuberculosis, measles, or varicella. Pertussis is primarily spread through respiratory droplets, not airborne transmission, so a negative-pressure room is not necessary.
C. Wear a surgical mask when providing care to the client.
Choice C: Wear a surgical mask when providing care to the client Wearing a surgical mask is appropriate when caring for a client with pertussis. Pertussis is spread through respiratory droplets, and wearing a mask helps prevent the transmission of the bacteria to healthcare workers and other patients.
D. Recommend that the client's family members receive antiviral therapy.
Choice D: Recommend that the client’s family members receive antiviral therapy Antiviral therapy is not effective against pertussis, which is a bacterial infection. Instead, antibiotics such as azithromycin or erythromycin are used to treat pertussis and prevent its spread. Therefore, recommending antiviral therapy would not be appropriate.
Full Explanation
The correct answer is: c. Wear a surgical mask when providing care to the client.
Choice A: Perform a Mantoux skin test on the client
The Mantoux skin test is used to screen for tuberculosis, not pertussis. Pertussis, also known as whooping cough, is a bacterial infection caused by Bordetella pertussis. The Mantoux test would not be relevant or helpful in diagnosing or managing pertussis.
Choice B: Assign the client to a negative-pressure airflow room
Negative-pressure airflow rooms are typically used for airborne infections such as tuberculosis, measles, or varicella. Pertussis is primarily spread through respiratory droplets, not airborne transmission, so a negative-pressure room is not necessary.
Choice C: Wear a surgical mask when providing care to the client
Wearing a surgical mask is appropriate when caring for a client with pertussis. Pertussis is spread through respiratory droplets, and wearing a mask helps prevent the transmission of the bacteria to healthcare workers and other patients.
Choice D: Recommend that the client’s family members receive antiviral therapy
Antiviral therapy is not effective against pertussis, which is a bacterial infection. Instead, antibiotics such as azithromycin or erythromycin are used to treat pertussis and prevent its spread. Therefore, recommending antiviral therapy would not be appropriate.