A client is experiencing a thyroid storm precipitated by a right lower lobe pneumonia. The vital signs are: HR-140/min; RR-28, B/P-196/54; T-101.4°F, Pulse Oximetry-96%. What action should the nurse take?

Prepare for endotracheal intubation and ventilatory support.

Provide continuous sedation for pain relief.

Initiate cardiac monitoring and assess for reflex bradycardia.

Maintain IV fluid infusion and assess adequacy of hydration.

Answer and Explanation

The Correct Answer is D

hoice A reason: Preparing for endotracheal intubation and ventilatory support is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with respiratory failure or impending airway obstruction, which are not the case for this client.

Choice B reason: Providing continuous sedation for pain relief is not the action that the nurse should take for a client with thyroid storm. This intervention may worsen the client's condition by suppressing the respiratory drive and lowering the blood pressure. The nurse should administer antithyroid medications, beta blockers, and corticosteroids as prescribed to reduce the thyroid hormone levels and the associated symptoms.

Choice C reason: Initiating cardiac monitoring and assessing for reflex bradycardia is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with hyperkalemia or digoxin toxicity, which are not the case for this client. The nurse should monitor the client's heart rate and rhythm, but not expect a reflex bradycardia, which is a paradoxical slowing of the heart rate in response to a rapid rise in blood pressure.

Choice D reason: Maintaining IV fluid infusion and assessing adequacy of hydration is the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with thyroid storm, as they are at risk of dehydration and electrolyte imbalance due to increased metabolic rate, fever, sweating, vomiting, and diarrhea. The nurse should administer isotonic fluids, such as normal saline, and monitor the client's fluid intake and output, urine specific gravity, and serum electrolytes.

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Correct Answer is D

Explanation

Choice A reason: Furosemide 40 mg PO daily is not the medication that the nurse should administer for chest pain. Furosemide is a diuretic that reduces fluid volume and lowers blood pressure, but it does not relieve anginal pain.

Choice B reason: Diltiazem 30 mg PO daily is not the medication that the nurse should administer for chest pain. Diltiazem is a calcium channel blocker that relaxes the blood vessels and lowers blood pressure, but it does not act quickly enough to relieve acute anginal pain.

Choice C reason: Metoprolol 25 mg PO bid is not the medication that the nurse should administer for chest pain. Metoprolol is a beta blocker that slows down the heart rate and lowers blood pressure, but it does not act quickly enough to relieve acute anginal pain.

Choice D reason: Nitroglycerin 0.4 mg SL PRN is the medication that the nurse should administer for chest pain. Nitroglycerin is a nitrate that dilates the coronary arteries and increases blood flow to the heart, thus relieving anginal pain. It is given sublingually (under the tongue) as needed for chest pain.

A. Have analgesic properties without sedation B. Can trigger vasodilation and improve blood flow C. Improve contractility and decrease afterload D. Inhibit platelet aggregation and clot formation

Correct Answer is A

Explanation

Choice A reason: Having analgesic properties without sedation is not the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel are antiplatelet drugs that prevent blood clots from forming in the arteries that supply the heart. They do not have significant analgesic or sedative effects.

Choice B reason: Triggering vasodilation and improving blood flow is not the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel do not directly cause vasodilation or increase blood flow. They work by reducing the stickiness of platelets and preventing them from clumping together and blocking the arteries.

Choice C reason: Improving contractility and decreasing afterload is not the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel do not affect the contractility or the afterload of the heart. They act on the blood vessels and the blood cells, not on the heart muscle. Contractility and afterload are influenced by other drugs such as beta-blockers, calcium channel blockers, and angiotensin-converting enzyme inhibitors.

Choice D reason: This is the correct answer. Inhibiting platelet aggregation and clot formation is the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel are antiplatelet drugs that interfere with the function of platelets, which are blood cells that help with clotting. By inhibiting platelet aggregation and clot formation, aspirin and clopidogrel reduce the risk of heart attack and stroke in people with coronary artery disease.

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A client is experiencing a thyroid storm precipitated by a right lower lobe pneumonia. The vital signs are: HR-140/min; RR-28, B/P-196/54; T-101.4°F, Pulse Oximetry-96%. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for a client diagnosed with cardiovascular disease and hypertension who is complaining of chest pain. Which medication should the nurse administer?

Correct Answer is D

Explanation

The nurse recognizes that the rationale for the medical prescription of aspirin 81 mg PO daily and clopidogrel 75 mg PO daily for the client with coronary artery disease is that these medications:

Correct Answer is A

Explanation

The nurse is providing medication teaching to a client prescribed lisinopril 10 mg PO daily. Which side effect of the medication will the nurse explain to the client is most common?

The nurse is caring for a client who is discharged with a prescription for amlodipine. The client should be instructed to self-monitor for:

The nurse has provided discharge teaching to a client prescribed nitroglycerin SL. Which statement, made by the client, indicates that the teaching has been effective? I will:

The client has been prescribed furosemide 40 mg IV to treat peripheral edema. Which method should the nurse use to best evaluate the client's response to this medication?

The nurse auscultates a systolic murmur in the second intercostal space to the right of the sternum while performing a cardiac assessment on a client. The nurse interprets this finding as:

Which statement, made by the client with coronary artery disease, alerts the nurse that the client may be experiencing difficulty adapting to the illness?

A client who is mentally impaired is incontinent of stool. What is the nurse's best intervention to help prevent skin breakdown?

The nurse is conducting dietary teaching for a client diagnosed with coronary artery disease. Which statement made by the client indicates an understanding of fat sources and the need to limit saturated fats?