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A client receiving thyroid replacement therapy following a thyroidectomy is seen in the dinic for a 6 weeks postoperative check-up. Which assessment is most important for the nurse to obtain?
- A. Report of bowel functioning since surgery.
- B. Heart rate and body weight.
- C. Number of any missed doses of medication.
- D. Daily caloric intake.
Correct Answer: B
Rationale: Heart rate and body weight assess thyroid replacement therapy effectiveness, reflecting metabolic rate changes.
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A client with heart failure (HF) returns to the clinic two weeks after adjustments were made to the prescribed cardiac glycoside, diuretic, and potassium supplement. The client's lungs are clear, heart rate is 58 beats/minute, and serum potassium level is 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
- A. Compare the weight with what it was at last visit.
- B. Report serum potassium to healthcare provider.
- C. Review the dietary history from the past week.
- D. Check the pretibial areas and ankles for edema.
Correct Answer: B
Rationale: Reporting hypokalemia (2.9 mEq/L) is critical to prevent arrhythmias, especially with cardiac glycosides.
The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?
- A. Place protective padding between the client and bed rails.
- B. Provide privacy for the client during the event.
- C. Observe the client's behavior during the event.
- D. Record the client's level of consciousness after the event.
Correct Answer: A
Rationale: Padding prevents injury during a seizure, prioritizing client safety over privacy or observation.
The nurse establishes a nursing problem of 'Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis.' Which nursing intervention should the nurse include in the plan of care for this client?
- A. Assist the client with learning how to set priorities and pace activities.
- B. Instruct the client about the importance of maintaining bedrest.
- C. Consult the discharge planner about transferring the client to an assisted living center.
- D. Offer assurance that the fatigue inducing stage of the disease does not last.
Correct Answer: A
Rationale: Pacing activities balances exertion and rest, reducing fatigue in rheumatoid arthritis, unlike bedrest, relocation, or reassurance.
The nurse has determined that a client with trigeminal neuralgia has the nursing problem, 'Imbalanced nutrition, less than body requirements.' Which cause is most likely contributing to the problem?
- A. Fatigue.
- B. Pain when eating.
- C. Nausea.
- D. Altered taste sensation.
Correct Answer: B
Rationale: Severe facial pain from trigeminal neuralgia deters eating, leading to imbalanced nutrition.
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Client describes a schedule for antacid use with other prescribed medications.
- B. Client selects a pattern of small meals alternating with fluid intake.
- C. Client expresses a willingness to reduce nicotine intake.
- D. Client agrees to participate in a variety of stress reduction techniques.
Correct Answer: B
Rationale: Small, frequent meals reduce rapid gastric emptying, addressing dumping syndrome symptoms post-Billroth II.