Nokea
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.
You may also like to solve these questions
Which instruction by the nurse concerning the test procedure is most accurate?
- A. You need to eat a large meal just before the test.
- B. You can drink coffee or tea in the morning before the test.
- C. You will be given a sweetened drink before the test.
Correct Answer: C
Rationale: A glucose tolerance test involves administering a sweetened drink to assess the body's response to glucose.
The nurse receives orders for the newly admitted client with Addison's disease. Which orders should the nurse question with the HCP? Select all that apply.
- A. Potassium 20 mEq oral now
- B. Sodium-restricted diet of 1000 mg
- C. Serum cortisol level in early am.
- D. Obtain serum glucose level now
- E. 5% dextrose in NS at 100 mL/hr
Correct Answer: A,B
Rationale: Potassium administration and a sodium-restricted diet are inappropriate as Addison's disease causes hyperkalemia and hyponatremia.
The nurse is administering morning medications. Which medications should the nurse administer question?
- A. The oral carafate to a client who has not eaten breakfast.
- B. The subcutaneous insulin to a client refusing blood glucose checks.
- C. The levothyroxine PO to a client diagnosed with hypothyroidism.
- D. The sliding scale insulin to a client whose blood glucose level is 320 mg/dL.
Correct Answer: B
Rationale: Insulin without glucose checks risks hypoglycemia, requiring clarification. Carafate timing, levothyroxine, and sliding-scale insulin are appropriate.
The client residing in a long-term care facility has type 2 DM and is sick with the stomach flu. The client's blood glucose is 245 mg/dL. Which action should the nurse take next?
- A. Have the client void and check the urine for ketones.
- B. Keep the client NPO until blood glucose levels decline.
- C. Immediately contact the client's health care provider.
- D. Continue to monitor blood glucose levels every 6 hours.
Correct Answer: A
Rationale: The nurse should check the client's urine for ketones whenever the blood glucose level is greater than 240 mg/dL.
Which finding indicates a potential complication of thyroid crisis that the nurse should prioritize?
- A. Heart rate of 140 beats per minute
- B. Blood pressure of 120/80 mmHg
- C. Temperature of 98.6°F
- D. Respiratory rate of 16 breaths per minute
Correct Answer: A
Rationale: A heart rate of 140 beats per minute indicates severe tachycardia, a life-threatening complication of thyroid crisis requiring immediate intervention.