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NO.1 A violent client remains in restraints for several hours. Which of the following interventions is
most appropriate while he is in restraints?
A. Assess skin integrity and circulation of extremities before applying restraints and as they are
removed.
B. Give fluids if the client requests them.
C. Release restraints every 2 hours for client to exercise.
D. Measure vital signs at least every 4 hours.
Answer: C

NCLEX-RN Free   
Explanation:
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or
refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly
while the client is restrained, not only before restraints are applied and
after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains
agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D)
Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle
tone, skin and joint integrity, and circulation.

NO.2 A client has returned to the unit from the recovery room after having a thyroidectomy. The
nurse knows that a major complication after a thyroidectomy is:
A. Fistula formation
B. Hypercalcemia
C. Respiratory obstruction
D. Myxedema
Answer: C

NCLEX-RN Quiz   
Explanation:
(A)
Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or tracheal
compression from hemorrhage is a major complication after a thyroidectomy.
(B)
Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a
major complication, not hypercalcemia. (C) Fistula formation is not a major complication associated
with a thyroidectomy. It is a major complication with a laryngectomy.(D) Myxedema is
hypothyroidism that occurs in adults and is not a complication of a thyroidectomy. A thyroidectomy
client tends to develop thyroid storm, which is excess production of thyroid hormone.