Nokea
The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?
- A. Weight gain.
- B. Hypoventilation.
- C. Cold intolerance.
- D. Lethargy
Correct Answer: B
Rationale: Hypoventilation can lead to hypoxemia and hypercapnia, requiring immediate intervention to prevent respiratory crisis. Other symptoms are common but not immediately life-threatening.
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The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?
- A. Take the diuretic every day, regardless of weight loss or muscle weakness.
- B. Weigh yourself daily at the same time and report excessive weight loss.
- C. Limit fluid intake while taking the diuretic to reduce fluid retention.
- D. Stop taking the medication when the edema in the lower extremities subsides.
Correct Answer: B
Rationale: Daily weight monitoring helps evaluate diuretic effectiveness and detect complications. Continuous diuretic use despite weakness, limiting fluids, or stopping medication without consultation can lead to adverse outcomes.
The nurse is evaluating a client's symptoms, and formulates the nursing problem, 'High risk for injury due to potential urinary tract infection.' Which symptoms indicate the need for this nursing problem?
- A. Straining on urination and nocturia
- B. Azotemia and anorexia.
- C. Hematuria and proteinuria.
- D. Fever and dysuria.
Correct Answer: D
Rationale: Fever and dysuria are classic UTI symptoms, indicating a risk for serious complications like pyelonephritis or sepsis. Other options suggest urinary issues but are less directly linked to injury risk.
A client receiving thyroid replacement therapy following a thyroidectomy is seen in the dinic for a 6 weeks postoperative check-up. Which assessment is most important for the nurse to obtain?
- A. Report of bowel functioning since surgery.
- B. Heart rate and body weight.
- C. Number of any missed doses of medication.
- D. Daily caloric intake.
Correct Answer: B
Rationale: Heart rate and body weight assess thyroid replacement therapy effectiveness, reflecting metabolic rate changes.
The healthcare provider prescribes cefazolin 800 mg IM every six hours. The available vial is labeled, 'Cefazolin 1 gram,' and the instructions for reconstitution state, For IM use add 2.5 mL sterile water for Injection to provide a total volume of 3.0 mL. After reconstitution, the solution contains how many mg/mL? Enter numeric value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 333
Rationale: One gram (1000 mg) reconstituted in 3.0 mL yields a concentration of 1000 mg / 3 mL = 333.33 mg/mL, rounded to 333 mg/mL.
A client is admitted to the emergency department 5 days after an acute coronary syndrome (ACS) troubled by severe fatigue, muscle weakness, and shortness of breath. The client's electrocardiogram (ECG) Indicates sinus tachycardia and the laboratory findings indicate an elevated serum brain natriuretic peptide (BNP) level. Which action is most important for the nurse to implement?
- A. Insert an indwelling urinary catheter.
- B. Obtain blood for serum cardiac enzymes.
- C. Provide emotional support.
- D. Auscultate lung fields for fine rales.
Correct Answer: D
Rationale: Auscultating for rales assesses for pulmonary congestion, indicated by elevated BNP and symptoms, prioritizing over catheter insertion or emotional support.