A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take?

Place the client on aspiration precautions.

Turn the client every 4 hours.

Check the client’s blood pressure every 2 hours.

Initiate measures to cool the client.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Place the client on aspiration precautions: Myxedema coma is a severe form of hypothyroidism that can lead to decreased mental function and a reduced level of consciousness. These conditions increase the risk of aspiration, which can lead to pneumonia and other complications. Therefore, placing the client on aspiration precautions is crucial to prevent these risks. Aspiration precautions may include elevating the head of the bed, monitoring swallowing ability, and providing thickened liquids if necessary.

Choice B Reason:

Turn the client every 4 hours: While turning the client regularly is important to prevent pressure ulcers, it is not the primary action needed for a client in a myxedema coma. The focus should be on stabilizing the client’s condition and preventing life-threatening complications such as aspiration, respiratory failure, and cardiovascular collapse.

Choice C Reason:

Check the client’s blood pressure every 2 hours: Monitoring vital signs, including blood pressure, is essential for clients in a myxedema coma. However, it is not the most critical action compared to preventing aspiration. Blood pressure should be monitored regularly, but the frequency can be adjusted based on the client’s condition and stability.

Choice D Reason:

Initiate measures to cool the client: Clients in a myxedema coma typically present with hypothermia (low body temperature), not hyperthermia (high body temperature). Therefore, initiating measures to cool the client would be inappropriate and could worsen their condition. Instead, measures to warm the client, such as using blankets and adjusting room temperature, are more appropriate.

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

Explanation

Choice A reason: A 22-year-old client with asthma is considered a priority for pneumonia vaccination. Asthma is a chronic respiratory condition that can increase the risk of complications from pneumonia. Vaccination helps protect against pneumococcal infections, which can be particularly severe in individuals with underlying respiratory conditions.

Choice B reason: A healthy 72-year-old client is also a priority for pneumonia vaccination. The Centers for Disease Control and Prevention (CDC) recommends pneumococcal vaccination for all adults aged 65 years and older. Older adults are at higher risk for pneumococcal disease due to age-related decline in immune function.

Choice C reason: A client with well-controlled diabetes should be prioritized for pneumonia vaccination. Diabetes can weaken the immune system, making individuals more susceptible to infections, including pneumonia. Vaccination is an important preventive measure for individuals with chronic health conditions.

Choice D reason: A client who is taking medication for hypertension is not necessarily a priority for pneumonia vaccination based solely on their hypertension. While hypertension is a common condition, it does not directly increase the risk of pneumococcal disease. However, if the client has other risk factors or comorbidities, they may still be considered for vaccination.

Choice E reason: A client who had a cholecystectomy last year is not a priority for pneumonia vaccination based on this surgical history alone. A cholecystectomy, which is the removal of the gallbladder, does not increase the risk of pneumococcal disease. Priority for vaccination is typically given to individuals with chronic health conditions, older adults, and those with weakened immune systems.

A. Document that the nasogastric tube is in the correct place. B. Notify the health care provider. C. Check for placement by auscultating for air injected into the tube. D. Retest the pH using another strip.

Correct Answer is B

Explanation

Choice A Reason:

Documenting that the nasogastric tube is in the correct place is not appropriate in this scenario. The normal pH range for gastric contents is typically between 1.5 and 3.5. A pH of 7.35 is much higher than this range, indicating that the tube may not be in the stomach. Therefore, documenting the tube as correctly placed could lead to potential complications, such as improper feeding or medication administration.

Choice B Reason:

Notifying the health care provider is the correct action. A pH of 7.35 suggests that the nasogastric tube may be misplaced, possibly in the respiratory tract or another non-gastric location. Immediate notification of the health care provider is crucial to prevent any adverse outcomes and to take corrective measures, such as confirming placement with an X-ray or re-inserting the tube.

Choice C Reason:

Checking for placement by auscultating for air injected into the tube is not a reliable method for verifying nasogastric tube placement. While this method was traditionally used, it has been found to be inaccurate and is no longer recommended. The sound of air entering the stomach can be misleading and does not confirm correct placement.

Choice D Reason:

Retesting the pH using another strip is not the best immediate action. While it is important to ensure the accuracy of the pH reading, a pH of 7.35 is significantly outside the normal gastric range, and retesting is unlikely to yield a different result. The priority should be to notify the health care provider to address the potential misplacement of the tube.

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A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply)

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

Explanation

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time?

Correct Answer is B

Explanation

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