While assessing a patient who has just arrived in the post-anesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains this data. Which is the most important to communicate to the surgeon?

The patient’s voice is weak and hoarse sounding.

The patient is complaining of a 7/10 incisional pain.

The patient’s cardiac monitor shows a heart rate of 112.

The patient is increasingly swelling at the neck.

Answer and Explanation

The Correct Answer is D

This is a critical finding that could indicate bleeding or compromised airway, both of which are potentially life-threatening complications following a thyroidectomy. Immediate intervention may be necessary to prevent further harm to the patient. The other options are important to note and should be addressed, but they do not require immediate intervention as the swelling in the neck does.

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Correct Answer is A

Explanation

Kegel exercises are designed to strengthen the pelvic ﬂoor muscles, which can help improve urinary incontinence. By teaching the patient how to perform Kegel exercises, the nurse can provide a non-invasive, eﬀective intervention that the patient can perform on her own to help manage her urinary incontinence.

Assisting the patient to the bathroom q3hr (b) may help reduce the frequency of incontinence episodes but it does not address the underlying issue of weakened pelvic ﬂoor muscles.

Demonstrating how to perform Crede’s maneuver (c) involves applying manual pressure to the bladder to assist with urination and is not appropriate for managing urinary incontinence related to laughing or coughing.

Placing a commode at the patient’s bedside (d) may be appropriate for patients who have difficulty with mobility or accessing the bathroom, but it does not address the underlying issue of weakened pelvic ﬂoor muscles causing urinary incontinence.

A. order a diet with no dairy products for the patient. B. explain to the patient why antibiotics are not being used. C. place the patient in a private room with contact isolation. D. Teach the patient about proper foal handling and storage.

Correct Answer is C

Explanation

Clostridium difficile is a highly contagious bacteria that can spread easily from person to person. The patient should be placed in a private room to prevent the spread of the infection to other patients. Contact isolation precautions should also be implemented, which involves wearing gloves and a gown when entering the patient's room, as well as washing hands thoroughly after leaving the room.

Options a and b are not directly related to the care of a patient with Clostridium difficile. Option d is also not directly related, although proper food handling and storage can help prevent the spread of other types of infections.

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While assessing a patient who has just arrived in the post-anesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains this data. Which is the most important to communicate to the surgeon?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After her bath, a 62-year-old patient asks the nurse for a perineal pad saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient?

Correct Answer is A

Explanation

A patient who is hospitalized with abdominal pain and watery, incontinent diarrhea is diagnosed with Clostridium difficile. In planning care for the patient, the nurse will:

Correct Answer is C

Explanation

A patient is taking high doses of prednisone to control the symptoms of acute exacerbation of systemic lupus erythematosus. When teaching the patient about the use of prednisone, which information is important for the nurse to include?

Cardiac monitoring is initiated for a patient with diabetic ketoacidosis. The nurse determines that this measure is important to identify:

A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been eﬀective?

When teaching a patient with chronic SIADH about long-term management of the disorder, the nurse determines that additional instruction is needed when the patient says:

The nurse is creating the care plan for a patient with symptoms of DI who was admited to the hospital for evaluation and treatment of the condition. An appropriate nursing diagnosis for the patient is:

The nurse is admitting a patient who is nauseated and vomiting up blood-streaked ﬂuid with diagnosis of acute gastritis. When obtaining the admission health history, it will be most important for the nurse to ask the patient about:

The nurse is caring for a client with diagnosis of peptic ulcer disease. Which assessment finding indicates to the nurse that the client most likely has an ulcer in the stomach rather than the duodenum?

Mr. D receives a daily injection of 70/30 NPH/regular insulin premix at 7:00 AM. The nurse expects that a hypoglycemic reaction is most likely to occur between: