Nokea
A nurse cares for a client who is recovering from a parathyroidectomy. When taking the client's blood pressure, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition?
- A. Serum potassium: 5.2 mEq/L
- B. Serum magnesium: 1.7 mEq/L
- C. Serum sodium: 144 mEq/L
- D. Serum calcium: 6 mg/dL
Correct Answer: D
Rationale: Hypocalcemia, indicated by a serum calcium level of 6 mg/dL, destabilizes excitable membranes, leading to muscle spasms and tetany, such as Trousseau's sign (flexion contractions). Potassium, magnesium, and sodium levels listed are not directly related to this condition.
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A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the second postoperative day the client states, 'I feel numbness and tingling around my mouth.' What action should the nurse take?
- A. Offer mouth care
- B. Loosen the dressing
- C. Assess for Chvostek's sign
- D. Ask the client orientation questions
Correct Answer: C
Rationale: Numbness and tingling around the mouth or in the fingers and toes are manifestations of hypocalcemia, which could progress to cause tetany and seizure activity. The nurse should assess for Chvostek's sign and Trousseau's sign to confirm hypocalcemia and notify the provider.
A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia. Which priority intervention should the nurse include in this client's plan of care?
- A. Monitor the electrolyte measurement once every shift
- B. Administer acetaminophen (Tylenol) for fever
- C. Ensure that working suction equipment is in the room
- D. Provide supplemental oxygen as needed
Correct Answer: C
Rationale: Clients with hypothyroidism and concurrent illness like pneumonia are at risk for myxedema coma, where maintaining an airway is critical. Ensuring working suction equipment is available is a priority to manage potential airway obstruction.
A nurse evaluates the following laboratory results for a client who has hypoparathyroidism: Calcium 7.2 mg/dL, Sodium 144 mEq/L, Magnesium 1.2 mEq/L, Potassium 5.7 mEq/L. Based on these results, which medications should the nurse anticipate administering?
- A. Oral potassium chloride
- B. Intravenous calcium chloride
- C. 50% normal saline IV solution
- D. 50% magnesium sulfate
- E. Oral calcitriol (Rocaltrol)
Correct Answer: B,D
Rationale: The client has hypocalcemia (calcium 7.2 mg/dL) and hypomagnesemia (magnesium 1.2 mEq/L), requiring intravenous calcium chloride and magnesium sulfate. Potassium is elevated, so potassium chloride is not needed. Sodium is normal, so saline is unnecessary, and no vitamin D deficiency is indicated.
A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first?
- A. Reassure the client that the voice change is temporary
- B. Notify the provider immediately
- C. Place the client in a high-Fowler's position and apply oxygen
- D. Prepare for emergency intubation
Correct Answer: D
Rationale: Stridor is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. The nurse should place the client in a high-Fowler's position and apply oxygen to maintain the airway while preparing to assist with emergency intubation or tracheostomy and notifying the provider or Rapid Response Team.
A nurse teaches a client who is prescribed an unsealed radioactive isotope. Which statements should the nurse include in this client's education?
- A. Do not share utensils, plates, or cups with anyone
- B. You can play with your grandchildren for 1 hour each day
- C. Eat foods high in vitamins such as apples, pears, and oranges
- D. Avoid contact with pregnant women and children
- E. Take a laxative 2 days after therapy to excrete the radiation
Correct Answer: A,D,E
Rationale: Clients receiving unsealed radioactive isotopes must avoid sharing utensils, contact with pregnant women and children, and take laxatives on days 2 and 3 to excrete radiation. Playing with grandchildren and eating specific fruits are not recommended due to radiation safety concerns.