A client has a history of atrial fibrillation and is taking an oral anticoagulant. The client has been newly diagnosed with hypothyroidism and placed on levothyroxine.
What assessment should the nurse prioritize?
Monitoring the client for increased bruising.
Assessing for signs and symptoms of infection.
Assessing the client’s level of consciousness.
Monitoring the client’s electrolyte levels.
The Correct Answer is A
This is because levothyroxine can increase the anticoagulant effect of oral anticoagulants and increase the risk of bleeding. The nurse should check the client’s prothrombin time and international normalized ratio (INR) regularly and report any abnormal values to the prescriber.
Choice B is wrong because hypothyroidism does not increase the risk of infection.
Choice C is wrong because hypothyroidism does not affect the level of consciousness unless it is severe and causes myxedema coma.
Choice D is wrong because hypothyroidism does not cause electrolyte imbalances.
Normal ranges for prothrombin time are 11 to 13.5 seconds and for INR are 0.8 to 1.22.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse would assess these factors to determine the need for therapy. Some possible explanations for the other choices are:
Choice A. Number of times client’s family reports the client is nauseated.
This is not a reliable indicator of the severity or cause of nausea and vomiting.
The nurse should assess the client directly and not rely on the family’s reports.
Choice B. How well the client is eating.
This is not a specific or objective measure of nausea and vomiting.
The client may have other reasons for not eating well, such as loss of appetite, taste changes, or pain.
The nurse should also monitor the client’s weight, hydration status, and electrolyte levels.
Choice D. Client’s nutritional status and fluid balance.
These are important aspects of the client’s overall health, but they are not directly related to nausea and vomiting.
The nurse should assess these factors as part of the comprehensive care plan, but they are not sufficient to determine the need for therapy.
Correct Answer is A
Explanation
Diaphoresis means excessive sweating, which is one of the symptoms of hypoglycemia. Hypoglycemia occurs when the blood sugar level is lower than the normal range, which can cause dizziness, confusion, weakness, hunger, and other signs.
Choice B is wrong because flushing of the face is not a symptom of hypoglycemia.
Flushing can be caused by other conditions, such as fever, allergic reactions, or rosacea.
Choice C is wrong because fruity breath is a symptom of hyperglycemia, not hypoglycemia.
Hyperglycemia means high blood sugar level, which can cause the body to produce ketones that give the breath a fruity odor.
Choice D is wrong because unpredictable behaviors are not a specific symptom of hypoglycemia.
However, hypoglycemia can cause confusion, irritability, or anxiety, which may affect the behavior of some people.
The normal range of blood sugar level for most people is between 70 and 130 mg/dL (3.9 and 7.2 mmol/L) before meals and less than 180 mg/dL (10 mmol/L) after meals.
However, this may vary depending on the individual and the type of diabetes.
It is important to monitor the blood sugar level regularly and treat hypoglycemia promptly by eating or drinking a simple sugar source.
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