Nokea
The client diagnosed with hyperthyroidism is complaining of being hot and cannot sit still. Which should the nurse do based on the assessment?
- A. Continue to monitor the client.
- B. Have the UAP take the client's vital signs.
- C. Request an order for a sedative.
- D. Insist the client lie down and rest.
Correct Answer: B
Rationale: Heat intolerance and restlessness are hyperthyroidism symptoms; vital signs assess for exacerbation (e.g., thyroid storm). Monitoring, sedatives, or rest are less appropriate.
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The nurse is caring for the client who had a thyroidectomy 2 days ago. Based on the findings of the client's serum laboratory report, which medication should the nurse plan to administer first?
- A. Potassium chloride 20 mEq oral bid
- B. Calcium gluconate 4.5 mEq IV once
- C. Dolasetron 12.5 mg IV as needed
- D. Levothyroxine 50 mcg oral daily
Correct Answer: B
Rationale: The serum calcium is critically low (6 mg/dL). Calcium gluconate addresses hypocalcemia from parathyroid gland damage during thyroidectomy.
During the physical assessment of this client, which finding the nurse's blood, the observer?
- A. Shortened height
- B. Enlarged hands
- C. Gonadal atrophy
- D. Loss of teeth
Correct Answer: B
Rationale: Acromegaly, caused by excess growth hormone, leads to enlarged hands due to soft tissue and bone overgrowth.
The client is immediate postprocedure endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse implement?
- A. Assess for rectal bleeding.
- B. Increase fluid intake.
- C. Assess gag reflex.
- D. Keep in supine position.
Correct Answer: C
Rationale: ERCP involves throat anesthesia; assessing the gag reflex ensures safe swallowing post-procedure. Rectal bleeding, fluids, and supine positioning are irrelevant.
Which instruction should the nurse give the client about insulin administration during periods of illness?
- A. Monitor blood glucose levels every 2 to 4 hours.
- B. Eat candy or sugar frequently.
- C. Attempt to drink a high-calorie beverage every hour.
- D. Test urine daily for protein.
Correct Answer: A
Rationale: Frequent blood glucose monitoring during illness helps adjust insulin doses to prevent complications.
The nurse is planning to complete noon assessments for four assigned clients with type 1 DM. All of the clients received subcutaneous insulin aspart at 0800 hours. Place the clients in the order of priority for the nurse's assessment.
- A. The 60-year-old client who is nauseated and has just vomited for the second time
- B. The 45-year-old client who is dyspneic and has chest pressure and new-onset atrial fibrillation
- C. The 75-year-old client with a fingerstick blood glucose level of 300 mg/dL
- D. The 50-year-old client with a fingerstick blood glucose level of 70 mg/dL
Correct Answer: B,A,C,D
Rationale: The 45-year-old client with dyspnea, chest pressure, and atrial fibrillation is at risk for a cardiac event, requiring immediate assessment. The 60-year-old with vomiting is next due to potential hypoglycemia. The 75-year-old with hyperglycemia needs attention but is less urgent. The 50-year-old with normal glucose is last.