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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Free Nursing Study Resources

Correct Answer is D

Explanation

A) Keep client in semi-Fowler's position with right extremity flat: Semi-Fowler's position is not optimal for a client with a compound fracture of the right tibia. Elevating the affected extremity, rather than keeping it flat, can help reduce swelling and pain.

B) Manage pain with oral opioids every 6 hr: While managing pain is crucial, oral opioids may not provide immediate relief needed in acute settings. Pain management should include a combination of strategies and may require IV analgesics for quicker relief.

C) Check capillary refill hourly for the first 24 hr: Although monitoring capillary refill is important to assess circulation, it is only one aspect of monitoring. Comprehensive assessment includes checking for signs of infection, neurovascular status, and compartment syndrome.

D) Apply a compression dressing over the fracture site: Applying a compression dressing can help control bleeding and reduce swelling. In a compound fracture, managing external bleeding and providing some stability to the fracture site are immediate priorities. However, the nurse should ensure this is done without compromising circulation and should be guided by physician orders.

A. "Sit with your legs in a dependent position when in a chair." B. "Prevent dehydration by drinking at least 2.5 liters fluids each day." C. "Massage your calves after sitting for 2 hours." D. "Roll stretchy nylon stockings down to the upper part of your calves."

Correct Answer is B

Explanation

A) "Sit with your legs in a dependent position when in a chair."
Sitting with legs in a dependent position can decrease blood flow and increase the risk of clot formation. It's important to elevate the legs when sitting to promote venous return and reduce the risk of deep-vein thrombosis (DVT).

B) "Prevent dehydration by drinking at least 2.5 liters fluids each day."
Staying well-hydrated helps maintain good blood circulation and prevents blood from becoming too viscous, reducing the risk of clot formation. Adequate fluid intake is crucial in preventing DVT.

C) "Massage your calves after sitting for 2 hours."
Massaging the calves is not recommended for someone with a history of DVT, as it may dislodge a clot. Instead, clients should be encouraged to move or stretch their legs regularly to improve circulation.

D) "Roll stretchy nylon stockings down to the upper part of your calves."
Proper use of compression stockings involves wearing them as prescribed, which typically means keeping them fully extended to ensure consistent pressure along the leg. Rolling them down can create a tourniquet effect and is not recommended.

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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 in an emergency department is caring for a client who has a compound fracture of the right tibia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in a clinic is teaching preventative measures with a female client who has a history of deep-vein thrombosis. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is monitoring a client who is taking captopril and has developed swelling of the lips and tongue. Which of the following actions should the nurse plan to take to manage this adverse medication reaction?

A nurse is teaching a client who has type 2 diabetes mellitus about a new prescription for glipizide. Which of the following instructions should the nurse include in the teaching?

A nurse is providing teaching to a client who has the communicable disease tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning a community education program about the communicable disease herpes zoster. Which of the following information should the nurse include in the teaching?

A nurse is discussing the five stages of grief by Kübler-Ross with a grief support group. Which of the following examples should the nurse identify as the first stage of the grief process?

A nurse is caring for a client who has an electrolyte imbalance with a potassium level of 6.4 mEq/L. Which of the following should the nurse administer?

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 in a provider's office is reviewing the laboratory report of a young adult female client who has had the communicable disease mononucleosis for the past 3 weeks. Which of the following laboratory results indicate the client is recovering from the virus?