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SimclexA client comes to the urgent care clinic complaining of right upper quadrant pain. The nurse
is examining a client and knows which of the following is NOT located in the RUQ?
1. Liver
2.Gallbladder
3. Dudoenum
4. Spleen
Answer: 4. Spleen
Rational: The spleen is located in the left upper quadrant.
Incorrect Answers::
Liver
This is located in the right upper quadrant.
Gallbladder
This is located in the right upper quadrant.
Duodenum
This is located in the right upper quadrant.
You have a client who has had epistaxis for the past 3 hours that hasn’t stopped since
waking up. What is the priority nursing intervention at this time?
1. Place pressure above the nostrils
2, Check a hemoglobin level
3.Have the client tip their head back
4. Look in the client's mouth
Answer: Place pressure above the nostrils
Rational: The priority is to stop the bleeding. Pressure placed above the nostrils is the most
effective way to apply pressure in a nosebleed.
Incorrect Answers:
,Check a hemoglobin level
This will occur, but the priority is to apply pressure to attempt to stop the bleeding.
Have the client tip their head back
Tilting the head back is contraindicated due to possibly getting blood in the airway.
Look in the client's mouth
There is no need to check inside the client's mouth. The priority is to attempt to stop the
bleeding.
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A nurse is checking a patient’s arm to select a site to start an IV. Which of the following veins
are located in the patient’s forearm for IV cannulation? Select all that apply.
1. Lesser saphenous vein
2. Cephalic Vein
3. Basilic Vein
4. Antebrachial Vein
5. Dorsal Plexus Vein
Correct Answer: 2,3,4
Rational:
1.Lesser saphenous vein
This vein is located in the leg.
,2.Cephalic vein
The forearm contains several veins that are accessible for starting an IV on a patient. One
example of these veins include the cephalic vein.
3.Basilic vein
This is also locate din the forearm which is accessible for starting an IV.
4. Antebrachial vein
This is among the veins found in the forearm.
5. Dorsal plexus vein
This vein is located in the hand.
A 36-year-old client must undergo a total thyroidectomy for treatment of thyroid cancer.
Which of the following has been shown as a complication of this type of surgery?
1. Voice Changes
2. Injury to Clavicle
3. Jugular Vein Distention
4. Hypercalcemia
Correct Answer: 1.Voice changes
Total thyroidectomy involves the removal of the thyroid gland from the neck. It may be done
as a response to thyroid cancer or in cases of a goiter or thyroid nodules when the gland is
no longer functional. Because of the location of the thyroid, the client is at risk of voice
changes associated with the surgery if the vocal cords are damaged during the surgical
procedure. The nurse monitors for dysphonia and a high-pitched voice postoperatively.
A nurse is caring for a postpartum client with a suspected deep vein thrombosis (DVT) in
one leg. What assessment findings would confirm this diagnosis? Select all that apply.
1. Discoloration of the affected leg
2.Cold foot on affected leg
3.One calf 3 cm larger than the other
4. Bilateral 2+ leg edema
5.Pedal pulses 1+ bilaterally
, Correct Answers and Rational:
1, 3
Discoloration of the affected leg
Discoloration is a sign there is a clot, because blood is moving in one leg and stagnant in the
other. Most often it will be red, but it could also be pale distal to the clot.
One calf 3 cm larger than the other
This is consistent with a DVT because blood is backed up in one leg and increasing edema
develops.
A nurse is experiencing severe stress after finishing a particularly busy shift. On the way
home, the nurse thinks about a project waiting at the house that needs to be finished and
feels even worse. The nurse says in the car on the way home, “You can do this. You are
strong.” Which type of communication does this best describe?
1. Intrapersonal communication
2.Interpersonal communication
3.Transpersonal communication
4.Self-disclosure communication
Correct Answer:
1. Intrapersonal communication
Intrapersonal communication describes 'self talk', or communication with oneself. In this
situation, the nurse is affirming personal abilities through intrapersonal communication.
Your client has noticed her nipples are enlarging and getting darker pigmented. What type of
pregnancy symptom is this?
1. Presumptive
2.Probable
3. Possible
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