Nokea
The nurse is preparing to care for four clients. In which order should the nurse plan to attend to the clients?
- A. Client following a thyroidectomy who has hoarseness and an SaO2 of 86%
- B. Client with hyperparathyroidism with a serum calcium level of 10.1 mg/dL
- C. Client with diabetes insipidus drinking frequently and asking for more cold water
- D. Client with hyperthyroidism who has a temperature of 102.2°F (39°C) and tachycardia
Correct Answer: A,D,C,B
Rationale: The thyroidectomy client with low SaO2 has a life-threatening airway issue, followed by the hyperthyroidism client at risk for thyroid storm, the DI client at risk for dehydration, and the stable hyperparathyroidism client last.
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The client is diagnosed with hypothyroidism. Which assessment data support this diagnosis?
- A. The client's vital signs are: T 99.0, P 110, R 26, and BP 145/80.
- B. The client complains of constipation and being constantly cold.
- C. The client has an intake of 780 mL and output of 256 mL.
- D. The client complains of a headache and has projectile vomiting.
Correct Answer: B
Rationale: Constipation and cold intolerance are classic hypothyroidism symptoms due to slowed metabolism. Tachycardia/hypertension, fluid imbalance, and vomiting are unrelated.
When the client asks how to store an opened vial of insulin, which answer by the nurse offers the most correct instruction?
- A. The best place for storing insulin is in the bathroom, close to the shower.
- B. The best place to store insulin is in the refrigerator.
- C. The best way to store insulin is at room temperature.
- D. The best place for storing insulin is in a warm location but out of sunlight.
Correct Answer: C
Rationale: Opened insulin vials can be stored at room temperature for up to 28 days for stability and comfort during injection.
The client is one (1) hour postoperative thyroidectomy. Which intervention should the nurse implement?
- A. Check the posterior neck for bleeding.
- B. Assess the client for the Chvostek's sign.
- C. Monitor the client's serum calcium level.
- D. Change the client's surgical dressing.
Correct Answer: A
Rationale: Checking for bleeding on the posterior neck prevents hematoma, a critical post-thyroidectomy complication. Chvostek’s, calcium, and dressing changes are secondary.
The client is ready for discharge following an adrenalectomy. Which statement that the client makes indicates the best understanding of the client's condition?
- A. I will continue on a low-sodium, low-potassium diet.'
- B. My husband has arranged for a marriage counselor because of our fights.'
- C. I will stay out of the sun so I will not turn splotchy brown.'
- D. I will take all of those pills every day.'
Correct Answer: D
Rationale: Lifelong steroid replacement is required post-adrenalectomy, and taking prescribed pills daily shows understanding. A high-sodium, low-potassium diet is needed, and photosensitivity is not an issue.
The nursing assistant reports to the nurse that the client's blood glucose reading is 58 mg/dL. What is the most appropriate nursing action at this time?
- A. The nurse is the need to be a condition.
- B. Give the client 1/4 cup of sweet fruit juice.
- C. Report the client's symptoms to the physician.
- D. Perform a complete head-to-toe assessment.
Correct Answer: B
Rationale: A blood glucose of 58 mg/dL with symptoms indicates hypoglycemia, requiring immediate administration of a fast-acting carbohydrate like fruit juice.