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A nurse is caring for a patient who is postoperative following a thyroidectomy. Which of the following findings should the nurse monitor for? Which finding should the nurse monitor post-thyroidectomy?
- A. Hypotension
- B. Tachycardia
- C. Hyperglycemia
- D. Bradypnea
Correct Answer: B
Rationale: The correct answer is B: Tachycardia. Following a thyroidectomy, the nurse should monitor for tachycardia due to the risk of thyroid storm, which can cause increased heart rate. Hypotension (A) is less common post-thyroidectomy. Hyperglycemia (C) is not a typical finding post-thyroidectomy. Bradypnea (D) is not expected, as respiratory rate should be monitored for signs of airway obstruction.
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A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints. What should the nurse's response be? What should the nurse respond to a request for restraints?
- A. I will call the doctor and get a prescription.
- B. I will cover the catheter so he can't see it.
- C. Let's wait until tonight to see if he continues this behavior.
- D. I will apply the restraints immediately.
Correct Answer: B
Rationale: The correct answer is B: "I will cover the catheter so he can't see it." This response addresses the root cause of the patient's behavior by removing the visual stimulus that may be prompting the patient to try to remove the IV catheter. By covering the catheter, the patient may be less likely to attempt to remove it. This approach is non-invasive and respects the patient's autonomy while also ensuring the safety of the IV site.
Choice A is incorrect because applying restraints should not be the first course of action without exploring less restrictive alternatives. Choice C delays addressing the issue and risks harm to the patient. Choice D is incorrect as applying restraints immediately is a more invasive intervention that should only be considered after less restrictive measures have been attempted.
A nurse manager is providing staff education about working with patients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? What should the nurse include in aggression training?
- A. Stand directly in front of the patient when talking.
- B. Know the layout of the facility.
- C. Bring security with you for all patient interactions.
- D. Provide immediate verbal feedback for escalating behavior.
- E. Avoid wearing necklaces during patient care.
Correct Answer: B,D,E
Rationale: Correct Answer: B, D, E
Rationale:
B: Knowing the layout of the facility is important for quick escape routes and safety measures during a patient's aggressive outburst.
D: Providing immediate verbal feedback for escalating behavior can help in de-escalating the situation and preventing further aggression.
E: Avoiding wearing necklaces during patient care can prevent them from being used as a weapon or trigger for aggressive behavior.
Summary:
A: Standing directly in front of the patient can be confrontational and escalate the situation.
C: Bringing security for all patient interactions may not be feasible or necessary in every situation.
F, G: No additional options are provided, but they would likely be incorrect as they were not included in the correct answer choices.
A nurse is conducting discharge teaching for a patient who has seizures and a new prescription for phenytoin. Which statements by the patient indicate a need for further teaching? Which statement indicates a need for phenytoin teaching?
- A. I know that I cannot switch brands of this medication.
- B. I have made an appointment to see my dentist next week.
- C. I will notify my doctor before taking any other medications.
- D. I'll be glad when I can stop taking this medicine.
Correct Answer: D
Rationale: The correct answer is D: "I'll be glad when I can stop taking this medicine." This statement indicates a need for further teaching because phenytoin is typically a lifelong medication for managing seizures. Stopping it abruptly can lead to serious consequences such as increased risk of seizures. Therefore, the patient should be educated on the importance of adhering to the prescribed regimen.
Choice A is correct because it emphasizes the importance of not switching brands of phenytoin, as different formulations may have varying levels of the active ingredient. Choice B is important for overall health but not directly related to phenytoin teaching. Choice C is also crucial as phenytoin can interact with other medications, so notifying the doctor is necessary.
In summary, choice D is incorrect because discontinuing phenytoin without medical supervision can be harmful. Choices A, B, and C are correct as they address important aspects of managing phenytoin therapy.
A nurse is preparing to administer clonidine 0.3 mg at bedtime to a patient. The available amount is clonidine 0.1 mg/tablet. How many tablets should the nurse administer per dose? How many clonidine tablets should the nurse administer?
Correct Answer: 3
Rationale: Correct Answer: 3
Rationale: To calculate the number of tablets needed, divide the total dose needed (0.3 mg) by the dose per tablet (0.1 mg). 0.3 mg ÷ 0.1 mg = 3 tablets. Therefore, the nurse should administer 3 tablets per dose.
Summary:
A: Incorrect - Not the correct number of tablets based on the dosage calculation.
B: Incorrect - Not the correct number of tablets based on the dosage calculation.
C: Incorrect - Not the correct number of tablets based on the dosage calculation.
D: Incorrect - Not the correct number of tablets based on the dosage calculation.
E: Incorrect - Not the correct number of tablets based on the dosage calculation.
F: Incorrect - Not the correct number of tablets based on the dosage calculation.
G: Incorrect - Not the correct number of tablets based on the dosage calculation.
A nurse is caring for a toddler. The nurse's observations are as follows: Heart rate: 150/min, Temperature: 38.9°C (102°F), Respiratory rate: 28/min, Oxygen saturation: 96% on room air, Blood Pressure: 90/43 mm Hg. What should the nurse do next? What should the nurse do next for toddler vital signs?
- A. Monitor the toddler's vital signs closely.
- B. Administer supplemental oxygen.
- C. Notify the healthcare provider.
- D. Reassess the toddler in 15 minutes.
Correct Answer: A
Rationale: Rationale: Option A is correct as the toddler's vital signs are within acceptable ranges. The heart rate, respiratory rate, and oxygen saturation are normal for a toddler. The elevated temperature may indicate a fever, but it is not alarming. The blood pressure is slightly low but still acceptable. Therefore, the nurse should monitor the toddler's vital signs closely to assess for any changes. Administering oxygen, notifying the healthcare provider, or reassessing in 15 minutes are not necessary at this point as the vital signs do not indicate immediate concern. Monitoring closely allows for timely detection of any deterioration or improvement in the toddler's condition.