Nokea
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.
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Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU?
- A. Glucose.
- B. Potassium.
- C. Calcium.
- D. Sodium.
Correct Answer: B
Rationale: DKA causes potassium depletion due to acidosis and diuresis; replacement is anticipated to prevent arrhythmias. Glucose is not an electrolyte, and calcium/sodium are less critical.
The client taking NPH insulin at 0800 reports feeling anxious and shaky in the midafternoon. Which intervention is best for the nurse to initiate?
- A. Have the client rate the level of anxiety.
- B. Give the client's prn dose of lorazepam.
- C. Check the client's fingerstick blood glucose level.
- D. Advise the client to sit in a recliner to relax.
Correct Answer: C
Rationale: The best intervention is to check a fingerstick blood glucose level because anxiety and shakiness in the midafternoon when taking NPH insulin could indicate hypoglycemia; NPH insulin peaks in 6-8 hours after administration.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which intervention should the nurse delegate to the UAP?
- A. Assist the client with abdominal pain to turn to the side and flex the knees.
- B. Monitor the Jackson Pratt drainage tube to ensure it is draining properly.
- C. Check to see if the client is sleeping after pain medication is administered.
- D. Empty the bedside commode of the client who has been having melena.
Correct Answer: A
Rationale: Assisting with positioning is within the UAP’s scope and promotes comfort. Monitoring drains, assessing sleep, and handling melena require RN skills.
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.
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.