A nurse is planning care for a client who is experiencing thyroid storm triggered by a systemic infection. Which of the following interventions should the nurse plan to take?

Request a prescription for levothyroxine IV.

Administer supplemental oxygen to the client.

Cover the client with warm blankets.

Implement measures to increase the client's pulse rate.

Answer and Explanation

The Correct Answer is B

A) "Limit sodium intake to 3,500 milligrams per day.":
Limiting sodium intake is crucial for managing heart failure to prevent fluid retention and exacerbation of symptoms. However, the recommended limit is typically much lower, around 1,500 to 2,000 milligrams per day, not 3,500 milligrams.

B) "Take ibuprofen for discomfort.":
Ibuprofen and other NSAIDs are not recommended for clients with heart failure as they can cause fluid retention, worsen heart failure symptoms, and increase the risk of kidney problems. Alternatives such as acetaminophen are generally safer for pain relief.

C) "Increase the distance you walk by 100 feet daily, even if you feel fatigued.":
While regular exercise is important, clients with heart failure should not push through fatigue, as overexertion can lead to worsening symptoms. Exercise recommendations should be tailored to the individual's tolerance and should be adjusted based on their energy levels.

D) "Include no more than 2,000 milliliters of fluid intake in 24 hours.":
Restricting fluid intake to 2,000 milliliters per day helps prevent fluid overload, which is critical for managing heart failure. Monitoring and limiting fluid intake can help control symptoms such as edema and shortness of breath.

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Correct Answer is A

Explanation

A) Initiate frequent, short periods of exercise throughout the day: Frequent, short periods of exercise are beneficial for a client with left-sided hemiplegia. Regular movement helps maintain joint flexibility, muscle strength, and overall functional ability. This approach can prevent complications such as contractures and muscle atrophy.

B) Decrease the amount of range of motion performed if tightness occurs: If tightness occurs, rather than decreasing range of motion, it is important to address it through appropriate stretching and adjustments in exercise technique. Reducing range of motion could lead to further loss of mobility and function.

C) Perform range-of-motion exercises to the affected side once per day: Performing range-of-motion exercises only once per day is generally insufficient. To maintain or improve mobility and prevent contractures, range-of-motion exercises should be performed multiple times throughout the day, as directed by the care plan.

D) Avoid repetitive movements during exercise: Repetitive movements are not necessarily harmful and can be beneficial for improving motor function and muscle coordination. However, it is important to balance repetitive exercises with variety and adjust based on the client’s condition and tolerance.

A. Place the client on his right side if tube resistance occurs. B. Check the tube patency every 4 hr. C. Flush the tube with 50 mL of 0.9% sodium chloride irrigation every 8 hr. D. Maintain the client in a supine position.

Correct Answer is B

Explanation

A) Place the client on his right side if tube resistance occurs: Positioning the client on the right side can help facilitate gastric emptying, but it is not a primary action to ensure NG tube patency. If tube resistance occurs, the nurse should assess and address the resistance more directly.

B) Check the tube patency every 4 hr: Regularly checking the tube patency ensures that the NG tube remains open and functional, preventing blockages and ensuring continuous decompression or feeding as required.

C) Flush the tube with 50 mL of 0.9% sodium chloride irrigation every 8 hr: Flushing the tube helps maintain patency, but the amount and frequency may vary based on facility protocols. Flushing every 8 hours might not be frequent enough to prevent blockages.

D) Maintain the client in a supine position: Keeping the client in a supine position is not recommended for maintaining NG tube patency and may increase the risk of aspiration. A semi-Fowler's position is usually preferred to promote drainage and reduce aspiration risk.

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A nurse is planning care for a client who is experiencing thyroid storm triggered by a systemic infection. Which of the following interventions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has left-sided hemiplegia. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is caring for a client who has an NG tube due to an intestinal obstruction. Using the nursing process for clinical decision making, which of the following actions should the nurse take to maintain NG patency?

Correct Answer is B

Explanation

A nurse is assessing a client who has hypocalcemia. Which of the following manifestations should the nurse expect?

A nurse is assessing an adolescent client who has the parasitic infection scabies. Which of the following findings should the nurse expect?

A nurse is preparing to teach a class at a community center for individuals who have hyperlipidemia. Which of the following nutritional recommendations should the nurse plan to include?

A nurse is educating a client who has gestational diabetes mellitus. Which of the following disease management strategies should the nurse include?

A nurse is providing teaching to a client who has gastroesophageal reflux disease. Which of the following statements should the nurse include in the teaching?

A nurse is planning care for a client who is experiencing thyroid storm triggered by a systemic infection. Which of the following interventions should the nurse plan to take?

A nurse is reviewing a client's laboratory results. The client's ABGS are as follows: pH 7.6, HCO3 24 mEq/L, PaCO2 30 mm Hg, PaO2 90 mm Hg. Which of the following acid-base imbalances should the nurse identify the client is experiencing?

A nurse is assessing a client who has anemia. Which of the following manifestations should the nurse expect?