A patient with primary hypothyroidism is showing early signs of myxedema coma.
In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

Measure body temperature.

Palpate for pedal edema.

Observe breathing patterns.

Assess blood pressure.

Answer and Explanation

The Correct Answer is C,A,D,B

Step 1: Observe breathing patterns. Respiratory depression is a critical symptom of myxedema coma that requires immediate attention.

Step 2: Measure body temperature. Hypothermia is a common symptom of myxedema coma and can provide important information about the severity of the patient’s condition.

Step 3: Assess blood pressure. Hypotension can occur in myxedema coma and can indicate the severity of the patient’s condition.

Step 4: Palpate for pedal edema. While this can be a symptom of hypothyroidism, it is not typically a primary concern in a patient showing signs of myxedema coma.

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Correct Answer is C

Explanation

Choice A rationale

Monitoring an IV infusion rate on an established schedule requires assessment skills and clinical judgement to identify and respond to potential complications. This task should be performed by a registered nurse.

Choice B rationale

Titration of oxygen to prescribed parameters is a complex task that requires advanced assessment skills and a deep understanding of the patient’s condition and response to treatment. This task should not be delegated to unlicensed assistive personnel (UAP).

Choice C rationale

Inserting a urinary catheter for an uncomplicated patient is a task that can be safely delegated to UAP who have been trained and demonstrated competence in this skill. It is a routine procedure and does not require advanced assessment or decision-making skills.

Choice D rationale

Procuring platelet products from the blood bank is a task that involves handling and transporting biological materials, which requires specific knowledge and skills. This task should not be delegated to UAP.

A. Check capillary refill on bilateral upper extremities. B. Administer morphine 2 mg IV as ordered. C. Perform range of motion exercises. D. Administer ondansetron 4 mg IV as ordered.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Checking capillary refill on bilateral upper extremities can help assess peripheral circulation and identify any potential vascular injuries.

Choice B rationale

Administering morphine 2 mg IV as ordered would help manage the patient’s pain.

Choice C rationale

Performing range of motion exercises may not be appropriate immediately after the fall and before the extent of the patient’s injuries are fully assessed.

Choice D rationale

Administering ondansetron 4 mg IV as ordered can help manage any nausea or vomiting that the patient may experience, which can be a side effect of the morphine or a result of the fall itself. TemazepamTemazepam Explore

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A patient with primary hypothyroidism is showing early signs of myxedema coma. In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

Nursing Test Bank

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Correct Answer is ["A","B","D"]

Explanation

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A patient with primary hypothyroidism is showing early signs of myxedema coma.
In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)