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During a thyroid storm, what is the nurse's priority intervention for a client experiencing increased heart rate and tremors?
- A. Administer antithyroid medications as prescribed.
- B. Administer a beta-blocker to control the heart rate.
- C. Monitor the client's temperature closely.
- D. Prepare the client for an emergency thyroidectomy.
Correct Answer: A
Rationale: The correct answer is to administer antithyroid medications as prescribed during a thyroid storm. Antithyroid medications help control the overproduction of thyroid hormones, which is crucial in managing symptoms such as increased heart rate and tremors. These symptoms can be life-threatening if not promptly addressed. Administering a beta-blocker (Choice B) may help control the heart rate, but addressing the underlying cause with antithyroid medications is the priority. Monitoring the client's temperature (Choice C) is important but not the priority intervention during a thyroid storm. Lastly, preparing the client for an emergency thyroidectomy (Choice D) is not the initial intervention for managing symptoms of a thyroid storm.
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A client with diabetes mellitus reports tingling in their feet. What is the nurse's best intervention?
- A. Advise the client to avoid wearing tight shoes.
- B. Refer the client to a podiatrist for foot care.
- C. Teach the client about blood sugar control and foot care.
- D. Administer insulin as prescribed.
Correct Answer: C
Rationale: The correct intervention for a client with diabetes mellitus experiencing tingling in their feet is to teach the client about blood sugar control and foot care. This is essential because tingling in the feet can be a sign of neuropathy, a common complication of diabetes. Educating the client on maintaining proper blood sugar levels and foot care practices can help manage neuropathy symptoms and prevent complications like ulcers or infections. Advising the client to avoid tight shoes (Choice A) may help with comfort but does not address the underlying issue. Referring the client to a podiatrist (Choice B) is important for foot care but does not directly address blood sugar control. Administering insulin (Choice D) is not the priority for managing tingling in the feet related to neuropathy.
The nurse is preparing to administer an intramuscular injection to an adult client. Which site should the nurse select?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Vastus lateralis muscle
- D. Dorsogluteal muscle
Correct Answer: B
Rationale: The ventrogluteal site is preferred for intramuscular injections in adults because it is free from major blood vessels and nerves, reducing the risk of injury. The deltoid muscle can be used for smaller volumes of medication, primarily vaccines. The vastus lateralis muscle is commonly used in infants, toddlers, and young children. The dorsogluteal muscle site is discouraged due to its proximity to the sciatic nerve, increasing the risk of injury or nerve damage.
An unlicensed assistive personnel (UAP), who usually works on a surgical unit, is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
- A. How long have you been a UAP and what units have you worked on?
- B. What type of care do you provide on the surgical unit, and what are the ages of the clients?
- C. What is your comfort level in caring for children and at what ages?
- D. Have you reviewed the list of expected skills you might need on this unit?
Correct Answer: D
Rationale: The most appropriate question by the charge nurse would be to ask the UAP if they have reviewed the list of expected skills needed on the pediatric unit. This ensures that the UAP is aware of the specific skills required for safe and appropriate care in that particular unit. Choices A, B, and C do not directly address the need for the UAP to review the expected skills, which is crucial for delegation decisions during floating assignments.
A client with a prescription for DNR begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
- A. Inform the healthcare provider
- B. Determine the client's need for pain medication
- C. Begin comfort measures
- D. Ensure all life-saving equipment is removed
Correct Answer: B
Rationale: The correct priority action for the nurse to implement in this scenario is to determine the client's need for pain medication. Ensuring that the client is comfortable and free from pain is crucial in end-of-life care, especially for a client with a Do Not Resuscitate (DNR) order. This action prioritizes the client's comfort and dignity in their final moments. While informing the healthcare provider and beginning comfort measures are important aspects of care, pain management takes precedence as the immediate priority. Removing life-saving equipment is not appropriate at this stage as it goes against the client's wishes stated in the DNR order.
Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?
- A. Witness the consent and sign the form as a witness
- B. Inform the client of alternatives to the procedure
- C. Explain the procedure in detail to the client
- D. Determine that the surgical consent form has been signed and is included in the client's record
Correct Answer: D
Rationale: The nurse's legal responsibility is to ensure that informed consent has been obtained by verifying that the client has signed the form and that it is included in the record. Witnessing the consent and signing as a witness is not the nurse's role, as this is typically done by a neutral party. Informing the client of alternatives to the procedure and explaining the procedure in detail are responsibilities of the healthcare provider performing the surgery, not the nurse.