Nokea
The nurse teaches the client how the infusion pump operates and correctly points out that the infusion is typically administered in which location?
- A. In a vein within the nondominant hand
- B. In the muscular tissue of the thigh
- C. In the subcutaneous tissue of the abdomen below the belt line
- D. In an implanted I.V. catheter threaded into the neck
Correct Answer: C
Rationale: Insulin pumps deliver insulin into the subcutaneous tissue of the abdomen for consistent absorption.
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A client who has just had a thyroidectomy returns to the unit in stable condition. What equipment is it essential for the nurse to have readily available?
- A. Tracheostomy set
- B. Thoracotomy tray
- C. Dressing set
- D. Ice collar
Correct Answer: A
Rationale: A tracheostomy set is essential post-thyroidectomy due to the risk of airway obstruction from swelling or hematoma.
The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care?
- A. Infuse 0.9% normal saline intravenously.
- B. Administer intermediate-acting insulin.
- C. Perform blood glucometer checks daily.
- D. Monitor arterial blood gas (ABG) results.
Correct Answer: A
Rationale: IV normal saline corrects severe dehydration in HHNS, a priority collaborative intervention. Insulin is secondary, daily glucose checks are insufficient, and ABGs are less critical in HHNS.
The nurse is caring for the client newly diagnosed with hypothyroidism. Which problem should the nurse include in the plan of care?
- A. Diarrhea due to gastrointestinal (GI) hypermotility
- B. Imbalanced nutrition due to insufficient calorie intake
- C. Activity intolerance due to increased metabolic rate
- D. Anxiety due to forgetfulness and slowed speech
Correct Answer: D
Rationale: Forgetfulness and slowed speech that occur with hypothyroidism can cause the client to be anxious.
The nurse discusses the long-term effects of diabetes mellitus with the client and realizes that the client needs further teaching when the client identifies which occurrence as a complication of this disease?
- A. Blindness
- B. Stroke
- C. Renal failure
- D. Liver failure
Correct Answer: D
Rationale: Liver failure is not a common complication of diabetes, unlike blindness, stroke, and renal failure.
At the beginning of thyroid replacement therapy after a thyroidectomy, the nurse must monitor the client closely for side effects. Which findings would the nurse expect to detect if the client is receiving more thyroid hormone replacement than required? Select all that apply.
- A. Hyperglycemia
- B. Tachycardia
- C. Insomnia
- D. Hirsutism
- E. Hypertension
Correct Answer: B,C,E
Rationale: Excess thyroid hormone can cause tachycardia, insomnia, and hypertension due to increased metabolic rate.