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The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
- A. Central venous pressure (CVP)
- B. Pulmonary artery capillary pressure (PACP)
- C. Pulmonary artery obstructive pressure (PACP)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The correct answer is C: Pulmonary artery obstructive pressure (PACP). The multilumen pulmonary artery catheter measures hemodynamic pressures in the heart. When the catheter tip enters small branches of the pulmonary artery, it can assess Central Venous Pressure (A), Pulmonary Artery Capillary Pressure (B), and Pulmonary Artery Wedge Pressure (D). Pulmonary artery obstructive pressure is not a standard hemodynamic measurement and is not assessed using this catheter. It is crucial to differentiate between the various pressures measured to accurately assess the patient's cardiac status.
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A total thyroidectomy is ordered following discovery of a cold nodule. In this case of hyperthyroidism versus malignancy, the nurse anticipates that the patient will have:
- A. A complete thyroidectomy also
- B. a partial thyroidectomy (approximately one-half of the thyroid is removed)
- C. a partial thyroidectomy (approximately five-sixths of the thyroid is removed)
- D. administration of thyroid medication
Correct Answer: A
Rationale: The correct answer is A: A complete thyroidectomy also. In the case of a cold nodule, which indicates potential malignancy, a total thyroidectomy is warranted to remove the entire thyroid gland to prevent the spread of cancer. A partial thyroidectomy, as in choices B and C, would not be sufficient in addressing malignancy. Administering thyroid medication, as in choice D, would not be appropriate for treating malignancy. Therefore, the correct approach is to perform a total thyroidectomy to ensure complete removal of the affected gland and to address both hyperthyroidism and potential malignancy.
The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
- A. Limit visits by family members
- B. Encourage the client to use a wheelchair
- C. Use the smallest needle possible for injections
- D. Maintain accurate fluid intake and output records
Correct Answer: C
Rationale: The correct answer is C: Use the smallest needle possible for injections. This is important for a client with thrombocytopenia because they have a low platelet count, leading to an increased risk of bleeding. Using a small needle minimizes the risk of causing bleeding or bruising during injections. Limiting family visits (choice A) is not directly related to protecting the client from bleeding. Encouraging wheelchair use (choice B) is not specifically relevant to protecting the client with thrombocytopenia. Maintaining accurate fluid intake and output records (choice D) is important but not directly related to preventing bleeding in a client with thrombocytopenia.
An adult had a total thyroidectomy. Which statement by the client demonstrates to the nurse an adequate understanding of long term care?
- A. “I will need to take replacement hormones for the rest of my life.”
- B. “ I should try to avoud stress and be alert for signs of recurrent hyperthyroidism.”
- C. “Thank goodness, this is over! I will never have to worry about throid problems again.”
- D. “ I should increase my caloric intake to replace what I lost during the surgery.”
Correct Answer: A
Rationale: The correct answer is A because after a total thyroidectomy, the client will no longer produce thyroid hormones, necessitating lifelong replacement therapy. This statement shows an understanding of the need for ongoing medication to maintain thyroid function. Choice B is incorrect as the client had a total thyroidectomy, so there is no risk of hyperthyroidism recurrence. Choice C is incorrect as the client will need ongoing care and monitoring for thyroid function. Choice D is incorrect as increasing caloric intake is not a necessary long-term care measure after a thyroidectomy.
What instruction should the nurse give to then patient taking propan0lol (Inderal) for hypertension?
- A. Have potassium level checked
- B. Do not stop medication abruptly
- C. Report any changes in appetite
- D. Resume usual daily activities
Correct Answer: B
Rationale: The correct answer is B: Do not stop medication abruptly. Abruptly stopping propranolol can lead to rebound hypertension and potentially life-threatening complications. The nurse should emphasize the importance of gradual tapering under medical supervision to avoid adverse effects.
A: Having potassium levels checked is not directly related to propranolol use for hypertension management.
C: Changes in appetite are not specific to propranolol use and may not be a significant concern compared to abrupt cessation of the medication.
D: Resuming usual daily activities is important but not as crucial as the correct instruction to avoid abrupt discontinuation of propranolol.
Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
- A. Obtain his oral temperature
- B. Allow him to wear his own clothing
- C. Encourage to perform his own personal
- D. Encourage him to be out of bed hygiene
Correct Answer: A
Rationale: The correct answer is A: Obtain his oral temperature. Seizure precautions typically include avoiding putting objects in the mouth to prevent injury during a seizure. Taking an oral temperature involves placing an object in the mouth, which could pose a risk if a seizure occurs. Choices B, C, and D are not contraindicated as they do not directly involve potential risks during a seizure. Allowing the patient to wear his own clothing, encouraging personal hygiene, and promoting mobility are safe practices that do not increase the risk of harm during a seizure.