A nurse is caring for a client who reports feeling nauseous immediately following a procedure using moderate (conscious) sedation. Which of the following should be the nurse's priority action?

Auscultate bowel sounds.

Turn the client on their side.

Administer ondansetron.

Ensure suction equipment is available.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Auscultate bowel sounds: While assessing bowel sounds can be important, it is not the priority action in this situation. The client is experiencing nausea, and the priority is to ensure their airway and safety, not just bowel function.

B. Turn the client on their side: Turning the client on their side is the priority action. This position helps prevent aspiration in case the client vomits, ensuring the airway remains clear and reducing the risk of aspiration pneumonia, especially after sedation.

C. Administer ondansetron: While ondansetron is effective for treating nausea, it is not the priority action in this case. The nurse should first ensure the client's safety by positioning them appropriately to prevent aspiration before administering medication.

D. Ensure suction equipment is available: Having suction equipment available is important for safety, but the immediate priority is positioning the client to prevent aspiration. Once the client is positioned safely, suction can be used if necessary, or be obtained if unavailable.

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Correct Answer is []

Explanation

Rationale for Correct Choices:

Hyperthyroidism: The client's symptoms—including a high fever, chest pain, palpitations, tremors, tachycardia, weight loss, diarrhea, and hyperactive bowel sounds—are indicative of hyperthyroidism. The lab results showing elevated T3 and T4 with suppressed TSH further support this diagnosis..
Place client on telemetry: Given the client's tachycardia (heart rate of 125/min), chest pain, and potential for arrhythmias (a common complication of hyperthyroidism), placing the client on telemetry is essential to monitor for any cardiac dysrhythmias.
Initiate hydration therapy: Hyperthyroidism can lead to dehydration due to increased metabolic activity and diarrhea. The client has reported weight loss and diarrhea, indicating the need for fluid replacement.
Cardiac dysrhythmias: Hyperthyroidism often causes tachycardia and increases the risk of arrhythmias, especially atrial fibrillation. Monitoring for cardiac dysrhythmias is crucial in this case to ensure the client’s heart rhythm is stable and to prevent complications.
Neurological Status: The client is oriented x 3 but appears nervous, agitated, and has tremors. In thyroid storm, severe agitation, delirium, psychosis, and even coma can develop. Close monitoring of neurological status is essential to assess the severity of encephalopathy.

Rationale for Incorrect Choices:

Hypoparathyroidism: Hypoparathyroidism typically causes symptoms such as muscle spasms, tetany, and hypocalcemia, which do not match the client’s presentation. The client has symptoms more consistent with hyperthyroidism.
Hypothyroidism: Hypothyroidism is characterized by fatigue, weight gain, bradycardia, and cold intolerance, which is the opposite of what the client is presenting with. The lab results (elevated T3 and T4 levels) also exclude hypothyroidism as a possibility.
Hyperparathyroidism: Hyperparathyroidism typically presents with hypercalcemia, muscle weakness, and fatigue. The client’s calcium levels are normal (9.5 mg/dL) and the clinical symptoms are more indicative of hyperthyroidism, not hyperparathyroidism.
Provide nutritional support: While nutritional support may be needed for managing hyperthyroidism long-term, it is not the priority action in this acute setting. Immediate interventions should focus on stabilizing the patient’s heart rate and fluid balance.
Check for Chvostek and Trousseau signs: Chvostek and Trousseau signs are used to assess for hypocalcemia, which is more relevant to conditions like hypoparathyroidism. In this case, hyperthyroidism is more likely, and these signs would not be helpful in this scenario.
Monitor for hypoglycemia: While endocrine disorders can sometimes have overlapping symptoms or comorbidities, there's no specific indication or direct risk for hypoglycemia from hyperthyroidism in this presentation.
Phosphorus levels: Phosphorus levels are typically monitored in cases involving kidney function, bone metabolism, or certain endocrine disorders like hypoparathyroidism or hyperparathyroidism, not hyperthyroidism.
Weight gain: Weight gain is not relevant in the context of hyperthyroidism, where the typical presentation includes weight loss despite an increased appetite. Monitoring weight gain would be more appropriate in cases of hypothyroidism.
Calcium levels: The client's calcium level is currently normal. While thyroid conditions can sometimes affect calcium, it's not the primary or most dynamic parameter to monitor for the acute phase and progress of thyroid storm compared to vital signs and mental status

A. Bounding radial pulse B. Alert and oriented to time, place, and person C. Lung sounds clear on auscultation D. Bowel sounds present in four quadrants on auscultation

Correct Answer is C

Explanation

Rationale:

A. Bounding radial pulse: A bounding radial pulse is not an indication of the effectiveness of bumetanide. It may suggest fluid overload or increased blood pressure, which is contrary to the goal of diuretic therapy in heart failure.

B. Alert and oriented to time, place, and person: While this indicates the client is neurologically stable, it does not specifically reflect the effectiveness of bumetanide, which is focused on reducing fluid overload and improving lung and cardiac function.

C. Lung sounds clear on auscultation: Clear lung sounds indicate that fluid buildup in the lungs, which is common in heart failure, has improved. Bumetanide is a diuretic that reduces fluid overload, and clear lung sounds are a key sign that the medication is effectively treating the client's condition.

D. Bowel sounds present in four quadrants on auscultation: While normal bowel sounds are important, they are not directly related to the effectiveness of bumetanide. Bumetanide’s primary effect is on fluid balance and lung function, not gastrointestinal function.

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A nurse is caring for a client who reports feeling nauseous immediately following a procedure using moderate (conscious) sedation. Which of the following should be the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse is preparing to administer bumetanide to a client who has heart failure. Which of the following findings indicates effectiveness of the medication?

Correct Answer is C

Explanation

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