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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. Trisodothyronine 3
- B. Phosphorus
- C. Calcium
- D. Thyroid-stimulating hormone
Correct Answer: A
Rationale: The correct answer is A: Trisodothyronine 3. In Graves' disease, there is excessive production of thyroid hormones, including triiodothyronine (T3). Elevated T3 levels are common in hyperthyroidism, which is a hallmark of Graves' disease. T3 is the active form of thyroid hormone and is responsible for regulating metabolism. Phosphorus, calcium, and thyroid-stimulating hormone levels are typically not elevated in Graves' disease. Phosphorus and calcium are more related to bone health and are usually within normal limits unless complications arise. Thyroid-stimulating hormone levels are usually suppressed in hyperthyroidism, including Graves' disease.
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A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
- A. Collect a urine sample
- B. Check the clients' vital signs
- C. Stop the infusion
- D. Administer oxygen to the client
Correct Answer: C
Rationale: The correct answer is C: Stop the infusion. The client is showing signs of a transfusion reaction, which can be serious. Stopping the infusion is the first priority to prevent further complications. Vital signs should be checked next to assess the client's condition. Collecting a urine sample is not a priority in this situation. Administering oxygen may be necessary depending on the client's condition, but stopping the infusion takes precedence.
A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?
- A. Make sure the client's room has positive pressure airflow.
- B. Make sure dietary plates and utensils are disposable.
- C. Wear an N95 respirator when providing direct client care.
- D. Monitor the client's temperature once every 6 hr.
Correct Answer: A
Rationale: Correct Answer: A: Make sure the client's room has positive pressure airflow.
Rationale:
1. Positive pressure airflow prevents contaminated air from entering the room, reducing the risk of infections.
2. It helps maintain a clean environment by keeping airborne pathogens out.
3. Protects the client who has a compromised immune system post-transplant.
Summary of Incorrect Choices:
B: Disposable utensils are important but do not directly protect the client from airborne infections.
C: N95 respirators are for the healthcare provider's protection, not the client's.
D: Monitoring temperature is essential but does not directly prevent infections in a protective isolation setting.
A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the feet.
- B. Keep the client's knees in a flexed position while they are in bed.
- C. Massage the client's legs every 4 hr while they are awake.
- D. Limit the client's fluid intake to 2
Correct Answer: A
Rationale: Correct Answer: A - Encourage the client to perform circumduction of the feet.
Rationale: Circumduction of the feet involves moving the feet in a circular motion, which helps promote blood circulation and prevent stasis in the lower extremities. This movement aids in preventing venous thromboembolism by reducing the risk of blood clots forming in the legs postoperatively. Encouraging this activity is crucial in maintaining vascular health and preventing complications.
Summary of Incorrect Choices:
B: Keeping the client's knees in a flexed position while in bed may lead to decreased circulation and increase the risk of venous stasis.
C: Massaging the client's legs every 4 hours can dislodge blood clots and increase the risk of embolism.
D: Limiting fluid intake can lead to dehydration, which can increase the risk of clot formation due to thicker blood consistency.
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 is caused by a lack of vitamin B12, leading to nerve damage. Paresthesia, or tingling and numbness in the extremities, is a common symptom. This poses a risk to the client's safety as it may result in decreased sensation and coordination, increasing the risk of falls and injuries. Loss of hearing (A), muscle wasting (C), and changes in vision (D) are not directly associated with pernicious anemia and do not pose an immediate safety risk in this context.
A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?
- A. Pedal edema
- B. Enlarged liver
- C. Dyspnea
- D. Neck vein distention
Correct Answer: C
Rationale: The correct answer is C: Dyspnea. Left-sided heart failure typically results in pulmonary congestion, leading to symptoms like dyspnea due to fluid accumulation in the lungs. Pedal edema (A) is more common in right-sided heart failure. Enlarged liver (B) is a sign of right-sided heart failure as well. Neck vein distention (D) is indicative of right-sided heart failure due to increased right atrial pressure. The focus in left-sided heart failure is on pulmonary symptoms, making dyspnea the most relevant manifestation.