A nurse is preparing to assess a client's thyroid gland. Which of the following actions should the nurse plan to take?
Instruct the client to take small sips of water.
Ask the client to hyperextend their neck during palpation.
Inspect the isthmus as the client holds their breath for 5 seconds.
Assist the client to a supine position prior to the assessment.
The Correct Answer is A
A. "Instruct the client to take small sips of water."
Having the client take small sips of water helps the nurse observe the thyroid gland as it moves up and down with swallowing, making abnormalities more noticeable.
B. "Ask the client to hyperextend their neck during palpation."
The client should slightly extend (not hyperextend) their neck to relax the muscles and allow for better palpation of the thyroid gland.
C. "Inspect the isthmus as the client holds their breath for 5 seconds."
The thyroid gland is best observed during swallowing, not by holding the breath.
D. "Assist the client to a supine position prior to the assessment."
Thyroid assessment is performed with the client in a sitting or standing position, not lying down.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Prime the IV tubing with lactated Ringer's. Blood products should only be primed with 0.9% sodium chloride (normal saline) because other solutions (e.g., lactated Ringer's or dextrose solutions) can cause hemolysis.
B. Use a 24-gauge IV catheter for the transfusion. A 24-gauge catheter is too small for a blood transfusion and may cause hemolysis or slow infusion. A large-bore catheter (18–20 gauge) is recommended for optimal flow.
C. Ensure that the IV tubing has an in-line filter. An in-line filter helps remove clots and debris, reducing the risk of transfusion reactions.
D. Prepare to change the tubing at least every 2 hr. Blood tubing should typically be changed after 4 hours or after two units of blood, whichever comes first, to prevent bacterial contamination.
Correct Answer is ["7.5"]
Explanation
To calculate the correct dosage, use the formula:
Dose to administer = (Desired dose/Available dose) ×Volume available
Given:
Desired dose = 30 mg
Available ,dose = 20 mg
Volume available = 5 mL
(30mg/20mg) × 5ml = 7.5ml
Final Answer:
7.5 mL
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