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The nurse observes a colleague caring for the client who had a hypophysectomy via the transsphenoidal approach 12 hours ago. Which action would require the observing nurse to intervene?
- A. Elevates the head of the client's bed to 30 degrees
- B. Gathers supplies to replace the bloody nasal packing
- C. Moisturizes the client's oral mucous membranes
- D. Places a cold washcloth over the client's swollen eyes
Correct Answer: B
Rationale: Nasal packing is left in place for 3-4 days post-hypophysectomy and should not be changed without an HCP order.
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The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective?
- A. The client has a three (3)-pound weight gain.
- B. The client has a decreased pulse rate.
- C. The client's temperature is WNL.
- D. The client denies any diaphoresis.
Correct Answer: C
Rationale: Normal temperature indicates corrected hypothermia from hypothyroidism. Weight gain, decreased pulse, and no diaphoresis are not specific indicators.
The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse?
- A. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation.
- B. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22.
- C. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28.
- D. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two (2) days ago and has a negative Trousseau's sign.
Correct Answer: C
Rationale: Addison’s with hypotension (80/45), tachycardia (124), and lethargy suggests adrenal crisis, requiring an experienced nurse. Ventilator care, stable Cushing’s, and post-thyroidectomy are less acute.
What is the best way to assess for hemorrhage in a client who has had a thyroidectomy?
- A. Check the pulse and blood pressure hourly.
- B. Roll the client to the side and check for evidence of bleeding.
- C. Ask the client if he/she feels blood trickling down the back of the throat.
- D. Place a hand under the client's neck and shoulders to feel bed linens.
Correct Answer: D
Rationale: Placing a hand under the neck and shoulders detects blood pooling under the incision, a common site for post-thyroidectomy hemorrhage.
Using the Dietary Exchange Plan for a 1,500 calorie diet in the chart below, which item is appropriate for the diabetic client to have in the midafternoon?
- A. An 8-oz carton of milk
- B. Two stream careers
- C. A medium apple
- D. A 2-oz slice of turkey
Correct Answer: C
Rationale: The midafternoon snack in the exchange plan includes one fruit serving, making a medium apple appropriate.
The client is admitted to the medical department with a diagnosis of rule-out (R/O) acute pancreatitis. Which laboratory values should the nurse monitor to confirm this diagnosis?
- A. Creatinine and (BUN).
- B. Troponin and (CK-MB).
- C. Serum amylase and lipase.
- D. Serum bilirubin and calcium.
Correct Answer: C
Rationale: Elevated amylase and lipase are specific for acute pancreatitis, confirming the diagnosis. Creatinine/BUN, troponin/CK-MB, and bilirubin/calcium are unrelated.