Nokea
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.
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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.
The client had a total pancreatectomy and splenectomy for cancer of the body of the pancreas. Which discharge instructions should the nurse teach? Select all that apply.
- A. Keep a careful record of intake and output.
- B. Use a stool softener or bulk laxative regularly.
- C. Use correct insulin injection technique.
- D. Take the pain medication before the pain gets too bad.
- E. Sleep with the head of the bed on blocks.
Correct Answer: B,C,D
Rationale: Stool softeners prevent constipation, insulin technique manages post-pancreatectomy diabetes, and proactive pain medication controls discomfort. I&O and elevated bed are unnecessary.
The female client is to be treated with radioactive iodine (RAI) therapy for an enlarged thyroid gland. The client asks if there are any precautions that are needed during RAI therapy. Which is the nurse's best response?
- A. No precautions are necessary. The radiation in the form of an oral capsule will target and destroy thyroid tissue only.'
- B. Use contraceptives or abstain from sexual intercourse to avoid conceiving during and for 6 months after treatment.'
- C. Discontinue taking the antithyroid medication and propranolol; results are seen immediately with RAI therapy.'
- D. Some people need a thyroid hormone replacement, but it is not necessary when the thyroid gland is enlarged.'
Correct Answer: B
Rationale: Pregnancy should be postponed for at least 6 months after RAI treatment because it crosses the placenta.
Immediately after surgery, the nurse assesses the client for bleeding. Where is the best location to assess for bleeding?
- A. The skull
- B. The nose
- C. The ear canal
- D. The tongue
Correct Answer: B
Rationale: Trans-sphenoidal hypophysectomy is performed through the nasal cavity, so bleeding is most likely to be observed in the nose.
Because the client is receiving levothyroxine (Synthroid) for the first time, the nurse recognizes the need to cheese the client to assess the effect of the effect of replacement therapy. For which signs and symptoms should the nurse assess? Select all that apply.
- A. Dyspnea
- B. Palpitations
- C. Excessive bruising
- D. Raised, red rash
- E. Hyperactivity
- F. Insomnia
Correct Answer: B,E,F
Rationale: Levothyroxine can cause signs of hyperthyroidism if overdosed, including palpitations, hyperactivity, and insomnia.