A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy.

Vital Signs

1100:

Temperature 37.4° C (99.4° F) Heart rate 98/min Respiratory rate 18/min

Blood pressure 128/68 mm Hg

Pulse oximetry 97% on room air

1115:

Temperature 37.8° C (100.1° F) Heart rate 110/min Respiratory rate 16/min

Blood pressure 138/74 mm Hg

Pulse oximetry 95% on room air

1130:

Temperature 38.6° C (101.5° F). Heart rate 136/min

Respiratory rate 16/min

Blood pressure 154/86 mm Hg

Pulse oximetry 95% on 2 L/min via nasal cannula

Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm.

Mental status

Wound drainage

Heart rate

Pain

Blood pressure

Temperature

Answer and Explanation

Correct Answer : A,C,E,F

A. This choice is correct because mental status changes, such as agitation, confusion, or delirium, are common signs of thyroid storm, which is a life-threatening complication of hyperthyroidism that occurs when there is excessive release of thyroid hormones.

B. This choice is incorrect because wound drainage is not a specific sign of thyroid storm, but rather a potential complication of any surgery that can indicate infection or bleeding.

C. This choice is correct because tachycardia, or increased heart rate, is a common sign of thyroid storm, which can result from increased metabolic demand and increased sensitivity to catecholamines.

D. This choice is incorrect because pain is not a specific sign of thyroid storm, but rather a common symptom of any surgery that can be managed with analgesics.

E. This choice is correct because hypertension, or increased blood pressure, is a common sign of thyroid storm, which can result from increased cardiac output and peripheral vascular resistance.

F. This choice is correct because hyperthermia, or increased temperature, is a common sign of thyroid storm, which can result from increased heat production and impaired heat dissipation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Incorrect. Withholding pain medications for 24 hr after the old patch is removed is a harmful action that could cause severe withdrawal symptoms and uncontrolled pain for the client. The nurse should respect the client's right to refuse treatment and explore the reasons for their decision.

B. Correct. Asking another nurse to witness the disposal of the new patch is a safe and legal action that follows the policies and procedures for handling controlled substances. The nurse should document the disposal of the new patch and report it to the appropriate authority.

C. Incorrect. Sealing the patches in a plastic bag and placing them in the client's trash basket is an unsafe and illegal action that could lead to diversion, misuse, or accidental exposure of fentanyl to others. The nurse should dispose of the patches in a secure and designated container that prevents access by unauthorized persons.

D. Incorrect. Sticking the two patches to each other and placing them in the sharps bin is an unsafe and improper action that could cause contamination, injury, or infection to others who handle or dispose of sharps waste. The nurse should dispose of the patches separately and carefully, avoiding contact with their adhesive surfaces.

A. Instruct the UAP to report any abnormal findings. B. Remind the UAP to check the client's pulse volume. C. Demonstrate the correct pulse site to the UAP. D. Confirm accuracy of the pulse rate obtained by the UAP.

Correct Answer is C

Explanation

A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate⁴.

To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse³⁵.

In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

Correct Answer is C

Explanation

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?

A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.)

A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective?

A client who had a knee replacement surgery and received a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL pre-filled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.)

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?