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A nurse is reviewing the laboratory findings of a client who has a new diagnosis of Graves' disease. The nurse should anticipate which of the following laboratory values to be elevated?
- A. Triiodothyronine
- B. Phosphorus
- C. Calcium
- D. Thyroid-stimulating hormone
Correct Answer: A
Rationale: The correct answer is A: Triiodothyronine. In Graves' disease, there is overproduction of thyroid hormones, including triiodothyronine (T3). Elevated T3 levels are characteristic due to increased thyroid hormone synthesis and release. Triiodothyronine is the active form of thyroid hormone, affecting metabolism, heart rate, and other body functions. Phosphorus (B), calcium (C), and thyroid-stimulating hormone (D) are not typically elevated in Graves' disease. Phosphorus and calcium levels may be normal or even decreased, as the disease primarily affects thyroid hormone levels. Thyroid-stimulating hormone is usually suppressed in Graves' disease due to the negative feedback mechanism of high thyroid hormone levels.
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A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
- A. Blood glucose of 110 mg/dL
- B. Decrease in blood pressure
- C. Increase in urinary output
- D. Respiratory rate of 10/min
Correct Answer: B
Rationale: The correct answer is B: Decrease in blood pressure. Telmisartan is an angiotensin II receptor blocker used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would indicate that the medication has been effective. Choice A, blood glucose of 110 mg/dL, is unrelated to the action of telmisartan. Choice C, increase in urinary output, is not a direct effect of telmisartan. Choice D, respiratory rate of 10/min, is not a typical indicator of the effectiveness of telmisartan in managing hypertension.
A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?
- A. Loss of hearing
- B. Paresthesia
- C. Muscle wasting
- D. Changes in vision
Correct Answer: B
Rationale: The correct answer is B: Paresthesia. Pernicious anemia leads to Vitamin B12 deficiency, causing nerve damage and paresthesia (tingling or burning sensation). This poses a risk to the client's safety as it can affect their balance and coordination, increasing the risk of falls and injuries. Loss of hearing (A), muscle wasting (C), and changes in vision (D) are potential manifestations of pernicious anemia but do not directly pose a risk to safety like paresthesia.
A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take?
- A. Withdraw the medication from the ampule using a needleless system.
- B. Place a paper towel around the ampule's neck to break off the top with both hands.
- C. Dispose of the top of the ampule in a sharps container.
- D. Expel air into the ampule to aspirate air bubbles.
Correct Answer: B
Rationale: The correct answer is B: Place a paper towel around the ampule's neck to break off the top with both hands. This method helps prevent injury as the paper towel provides grip and protection. Breaking the ampule's top with both hands reduces the risk of glass shards. Using a needleless system (A) is not necessary for breaking an ampule. Disposing the top in a sharps container (C) is important, but it is not the immediate action for withdrawing medication. Expelling air into the ampule (D) is unnecessary and may introduce air bubbles into the medication.
A nurse is assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 13 mm at the injection site. Which of the following instructions should the nurse provide to the client?
- A. You will need to have the skin test annually.
- B. You will need to return in 48 hours for re-evaluation.
- C. Your test will need to be repeated at this time.
- D. You will need to follow up with your provider.
Correct Answer: D
Rationale: The correct answer is D: "You will need to follow up with your provider." The nurse should instruct the client to follow up with their provider because an induration of 13 mm at 48 hours post-PPD indicates a positive result for tuberculosis exposure. Follow-up is necessary to determine if treatment or further evaluation is needed. Choice A is incorrect because annual skin tests are not necessary unless there is ongoing exposure or risk factors. Choice B is incorrect as the client does not need to return in 48 hours for re-evaluation since the test has already been read at 48 hours. Choice C is incorrect as repeating the test is not necessary when a positive result is already present.
A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?
- A. Obtain an ECG.
- B. Administer an opioid pain medication.
- C. Infuse IV fluids to maintain urine output at 75 mL/hr.
- D. Change dressings over the entrance and exit wounds.
Correct Answer: A
Rationale: The correct answer is A: Obtain an ECG. The first step in managing a client with an electrical shock injury is to assess for any cardiac complications, as electrical shock can cause arrhythmias. Obtaining an ECG will help the nurse identify any abnormal heart rhythms and determine the need for immediate intervention. Administering opioid pain medication (B) is not a priority as assessing the cardiac status takes precedence. Infusing IV fluids (C) is important but not the first priority. Changing dressings (D) can wait until the client's immediate medical needs are addressed.