The nurse is assessing a client taking prescribed propylthiouracil (PTU) therapy. What should the nurse further assess?

Decreased nervousness

Sore throat and increased ecchymosis

Heart rate greater than 60 and less than 100 beats/min

Reduced tremor

Answer and Explanation

The Correct Answer is B

A. Decreased nervousness might be a result of effective treatment for hyperthyroidism, but it is not the most critical symptom to assess in relation to propylthiouracil (PTU) therapy.
B. Sore throat and increased ecchymosis Propylthiouracil (PTU) can cause serious side effects, including agranulocytosis (a severe decrease in white blood cells), which can result in sore throat, fever, and increased bruising or ecchymosis. These symptoms suggest a possible infection or bleeding disorder and should be promptly assessed and reported to a healthcare provider.
C. Heart rate greater than 60 and less than 100 beats/min PTU is used to treat hyperthyroidism, which can cause an elevated heart rate. A heart rate between 60 and 100 beats per minute is generally within normal limits and does not specifically warrant further assessment in this case.
D. A reduced tremor may be a positive sign of treatment effectiveness, as tremors are common in hyperthyroidism. However, this does not necessitate further assessment related to PTU therapy, unlike more serious side effects such as agranulocytosis.

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Correct Answer is A

Explanation

A. Rubbing the injection site after insulin administration is not recommended, as it can increase the risk of bruising or irritation. Insulin should be injected into the subcutaneous tissue, and massaging or rubbing the site can cause the insulin to be absorbed too quickly, leading to unpredictable blood sugar levels.
B. Injecting the needle at a 90-degree angle is the correct technique for subcutaneous insulin injection, especially when using shorter needles. A 90-degree angle ensures the insulin is delivered into the subcutaneous tissue.
C. Grasping the skin helps to ensure that the insulin is injected into the subcutaneous layer and not into the muscle, which can affect absorption.
D. Rotating injection sites is important to prevent tissue damage or lipodystrophy (thickening or atrophy of the skin). Following a pattern helps ensure that insulin is injected into different areas for consistent absorption.

A. "Between 0930 and 1130." B. "Between 1130 and 1330." C. "Between 0930 and 1030. D. "Between 1130 and 1930."

Correct Answer is A

Explanation

A. Regular insulin typically reaches its peak action 2 to 4 hours after administration. Since the insulin was given at 0730, the nurse should be most alert for signs of hypoglycemia between 0930 and 1130 when the insulin is most effective in lowering blood glucose.
B. This time frame is too late for peak action, as regular insulin's peak typically occurs earlier, between 2 to 4 hours after administration.
C. While this is within the range of insulin’s peak effect, it doesn't account for the full duration of potential hypoglycemia. The best window for observing symptoms would extend until 1130.
D. Hypoglycemia is most likely to occur during the peak action of the insulin, which is earlier, not this extended time frame.

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The nurse is assessing a client taking prescribed propylthiouracil (PTU) therapy. What should the nurse further assess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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