A nurse notes that a client's eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect?

Decreased calcium levels

Decreased somatotropin levels

Increased glucose levels

Increased T4 levels

Answer and Explanation

The Correct Answer is D

Rationale:
A. Decreased calcium levels: Hypocalcemia may cause neuromuscular symptoms such as tetany or tingling but is not associated with exophthalmos (protruding eyes). Calcium imbalance does not typically cause changes in eye appearance.

B. Decreased somatotropin levels: Somatotropin (growth hormone) deficiency may lead to growth delay or reduced muscle mass, but it is not associated with changes in orbital appearance. Protruding eyes are unrelated to growth hormone levels.

C. Increased glucose levels: Elevated glucose is characteristic of diabetes mellitus and may lead to complications like neuropathy or retinopathy, but it does not cause eye protrusion.

D. Increased T4 levels: Elevated thyroxine (T4) is seen in hyperthyroidism, particularly in Graves' disease, which is strongly associated with exophthalmos. The protrusion results from inflammation and edema of orbital tissues, a hallmark of this thyroid disorder.

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Correct Answer is D

Explanation

Rationale:
A. Contact precautions: Contact precautions are used for infections spread by direct or indirect contact, such as Clostridioides difficile or MRSA. Tuberculosis is transmitted through airborne particles, not contact.

B. Protective environment precautions: Protective environments are for immunocompromised clients, such as those undergoing stem cell transplants, to protect them from external infections. This does not apply to clients with active infections like tuberculosis.

C. Droplet precautions: Droplet precautions are used for infections spread through large respiratory droplets, like influenza or pertussis. Tuberculosis is spread via much smaller airborne particles that remain suspended in the air.

D. Airborne precautions: Airborne precautions are required for tuberculosis because it is spread through tiny airborne droplets. These precautions include placing the client in a negative pressure room and having staff wear an N95 respirator when entering the room.

A. Wear a protective gown when suctioning the client's airway. B. Monitor for oral secretions every 2 hr. C. Provide oral care every 2 hr. D. Maintain the client in a supine position. E. Assess the client daily for readiness of extubation.

Correct Answer is ["B","C","E"]

Explanation

Rationale:
A. Wear a protective gown when suctioning the client's airway: While wearing appropriate personal protective equipment protects the nurse from contamination, it does not directly reduce the client’s risk for ventilator-associated pneumonia.

B. Monitor for oral secretions every 2 hr: Regular assessment for and removal of oral secretions reduces the risk of aspiration, which is a key contributor to the development of ventilator-associated pneumonia.

C. Provide oral care every 2 hr: Frequent oral hygiene decreases the colonization of bacteria in the oropharynx, thereby reducing the risk of these organisms being aspirated into the lungs and causing infection.

D. Maintain the client in a supine position: Keeping the client supine increases the risk of aspiration. To prevent VAP, the head of the bed should typically be elevated 30 to 45 degrees unless contraindicated.

E. Assess the client daily for readiness of extubation: Daily evaluation for weaning from the ventilator reduces the duration of mechanical ventilation, which directly lowers the risk of developing ventilator-associated pneumonia.

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A nurse notes that a client's eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the client's risk for ventilator-associated pneumonia (VAP)? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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