Nokea
Vital signs
Temperature 95 F (35 C)
Blood pressure 90/50 mm Hg
Heart rate 50/min
Respirations 6/min
SpO2 83%
The nurse is caring for a client with hypothyroidism who has become lethargic and difficult to rouse. Which action is the priority?
- A. Administer scheduled PO levothyroxine
- B. Perform bag-valve-mask ventilation
- C. Place a warming blanket on the client
- D. Review client's thyroid laboratory results
Correct Answer: B
Rationale: Lethargy and unresponsiveness in hypothyroidism suggest myxedema coma, requiring immediate airway management with ventilation (B). Levothyroxine (A), warming (C), and lab review (D) are secondary.
You may also like to solve these questions
The nurse is caring for a hospitalized client. Which is the best example of narrative documentation to provide legal malpractice protection for the nurse after an adverse event?
- A. Client found on floor this morning at 6:50 AM. No verbalized symptoms. I think client tripped over a cord. Client instructed on safety during ambulation.'
- B. Client reports IV pole hit head at 7:30 AM. Denies pain. IV pole removed for client safety. Will continue to monitor. Health care provider (HCP) notified.'
- C. IV site in right hand is red and swollen at 9:30 AM. IV line removed, bleeding controlled, and warm compress administered at 9:40 AM. Will monitor for swelling and pain every hour.'
- D. Package of green leaves found in client drawer at 1:00 PM. Client acting suspicious at 2:00 PM. HCP notified. Will call security. Client has multiple tattoos and piercings.'
Correct Answer: C
Rationale: Detailed, objective documentation (C) with times, actions, and follow-up plans provides the best legal protection. Options A, B, and D include assumptions, vague details, or irrelevant information.
The nurse caring for a client scheduled for an angiogram should prepare the client for the procedure by telling him to expect:
- A. Dizziness as the dye is injected.
- B. Nausea and vomiting after the procedure is completed.
- C. A decreased heart rate for several hours after the procedure is completed.
- D. A warm sensation as the dye is injected.
Correct Answer: D
Rationale: A warm sensation is common during dye injection in an angiogram. Dizziness , nausea , and decreased heart rate are not typical.
Laboratory reference ranges
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
Potassium
3.5-5 mEq/L
(3.5-5 mmol/L)
The nurse is administering prescribed medications to assigned clients. The nurse should hold and seek clarification for which scheduled administrations? Select all that apply.
- A. client with cirrhosis had 2 stools today, lactulose prescribed daily
- B. client receiving IV vancomycin; mild facial flushing noted after 30 minutes
- C. client scheduled for abdominal surgery tomorrow; vitamin E PO prescribed daily
- D. client prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L (5.6 mmol/L)
- E. client with diabetes mellitus has insulin glargine and aspart prescribed, AM glucose is 100 mg/dL (5.6 mmol/L)
Correct Answer: B, C, D
Rationale: Vancomycin flushing (B) suggests red man syndrome, vitamin E (C) increases bleeding risk pre-surgery, and hyperkalemia (D) contraindicates lisinopril. Lactulose (A) and insulin (E) are appropriate.
Which of the following toys is the most appropriate for a 2-year old with Tetralogy of Fallot?
- A. A toy horn
- B. A stethoscope
- C. A push-pull toy
- D. A shape sorter
Correct Answer: C
Rationale: A push-pull toy encourages gentle physical activity suitable for a 2-year-old with Tetralogy of Fallot, who may tire easily. A toy horn requires exertion, a stethoscope is not age-appropriate, and a shape sorter is sedentary.
The nurse is reinforcing teaching for a client with bipolar disorder who has a new prescription for lithium. Which of the following statements by the client would require follow-up?
- A. I should drink at least 2 to 3 L of fluid daily.'
- B. I can take over-the-counter ibuprofen for pain relief.'
- C. I will maintain a consistent dietary intake of sodium.'
- D. I should have my medication levels checked periodically.'
Correct Answer: B
Rationale: Ibuprofen (B) can increase lithium toxicity, requiring follow-up. Adequate fluid intake (A), consistent sodium (C), and periodic level checks (D) are correct.