The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?

A tracheotomy set
A padded tongue blade
An endotracheal tube
An airway

Solution

Answer A is correct. The client who has recently had a thyroidectomy is at risk for tracheal edema. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem, so answers C and D will not work. A padded tongue blade is used for seizures and is not used for the client with tracheal edema, so answer D is incorrect.

Which task should be assigned to the nursing assistant?

Placing the client in seclusion
Emptying the Foley catheter of the preeclamptic client
Feeding the client with dementia
Ambulating the client with a fractured hip

Solution

Answer C is correct. Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. An RN or the physician can place the client in seclusion, so answer A is incorrect. Answer B is incorrect because the nurse should empty the Foley catheter of the preeclamptic client because the client is unstable. Answer D is incorrect because a nurse or physical therapist should ambulate the client with a fractured hip.

A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:

Douche after intercourse
Void every 3 hours
Obtain a urinalysis monthly
Wipe from back to front after voiding

Solution

Answer B is correct. Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Answer A is incorrect because douching is not recommended. Answer C is incorrect because obtaining a urinalysis monthly is not necessary. Answer D is incorrect because the client should practice wiping from front to back after voiding and bowel movements.

The nurse has a pre-op order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:

Administer the medications together in one syringe
Administer the medications separately
Administer the Valium, wait 5 minutes, and administer the Phenergan
Question the order because they cannot be given to the same client

Solution

Answer B is correct. Answer A is incorrect because Valium (diazepam) is not administered with other medications. Both medications can be given to the same client, so answer D is incorrect. Answer C is not necessary, therefore is incorrect.

A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:

Be injected into the deltoid muscle
Be injected in the abdomen
Aspirate after the injection
Clear the air from the syringe before injections

Solution

Answer B is correct. Answer A is incorrect because Lovenox injections should be given in the abdomen. Answers C and D are incorrect because the client should not aspirate after the injection or clear the air from the syringe before injection.

The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

Atrial flutter
A sinus rhythm
Ventricular tachycardia
Atrial fibrillation

Solution

Answer C is correct. The graft indicates ventricular tachycardia. The others are not noted on the ECG strip, so answers A, B, and D are incorrect.

The nurse is evaluating the client who is dilated 8cm. The following graph is noted on the monitor. Which action should be taken first by the nurse?

Instructing the client to push
Performing a vaginal exam
Turning off the Pitocin infusion
Placing the client in a semi-Fowler’s position

Solution

Answer C is correct. The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing might increase the decelerations and because the client is 8cm dilated. Performing a vaginal exam should be done after turning off the Pitocin. Therefore, answers A, B, and D are incorrect.

A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:

Determines the lung maturity of the fetus
Measures the activity of the fetus
Shows the effect of contractions on fetal heart rate
Measures the neurological well-being of the fetus

Solution

Answer B is correct. A nonstress test determines periodic movement of the fetus. It does not determine lung maturity, show contractions, or measure neurological wellbeing, so answers A, C, and D are incorrect.

The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

Tire easily
Grow normally
Need more calories
Be more susceptible to viral infections

Solution

Answer A is correct. The toddler with a ventricular septal defect will tire easily. Answer B is incorrect because he will be small for his age. He will not need more calories, so answer C is incorrect. He will be susceptible to bacterial infection, but he will be no more susceptible to viral infections than other children, so answer D is incorrect.

The nurse is educating the lady’s club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence.

Solution

See diagram. The Tail of Spence is located in the upper outer quadrant of the breast.

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