The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

Weight gain.

Hypoventilation.

Cold intolerance.

Lethargy

Answer and Explanation

The Correct Answer is B

A.   Weight gain is a common symptom of hypothyroidism but it is not an immediate threat to life. It can be managed with diet and medication.
B.   Hypoventilation, or decreased respiratory rate, can lead to hypoxemia (low oxygen levels in the blood) and hypercapnia (increased carbon dioxide levels in the blood). These conditions can rapidly deteriorate into a respiratory crisis and require immediate intervention.
C.   Cold intolerance is a common symptom of hypothyroidism but is not an immediate threat to life. It can be managed with warm clothing and a warm environment.
D.   Lethargy is another common symptom of hypothyroidism but is not an immediate threat to life. It can be managed with medication and lifestyle changes.
8.   The nurse reviews discharge instructions with a client

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Correct Answer is ["31"]

Explanation

Total volume in mL x Drop factor) / Total time in minutes.

For the vancomycin infusion, the total volume is 250 mL, the drop factor is 15 gtt/mL, and the total time is 120 minutes (2 hours).

The calculation is as follows: (250 mL x 15 gtt/mL) / 120 minutes = 31.25 gtt/min.

After rounding to the nearest whole number, the nurse should regulate the infusion to 31 gtt/min.

A. Client's breath sounds are clear to auscultation bilaterally. B. Client exhibits a frequent productive cough. C. Client demonstrates proper use of an incentive spirometer. D. Client reports using the incentive spirometer every hour while awake.

Correct Answer is A

Explanation

A. Clear breath sounds indicate effective ventilation and oxygenation, which are the desired outcomes of incentive spirometry. This outcome directly reflects the effectiveness of the incentive spirometer in preventing atelectasis and improving lung expansion.
B. A productive cough suggests mobilization of secretions. While this is important for airway clearance, it is not a direct measure of the effectiveness of the incentive spirometer. This outcome is related to airway clearance, but not specifically to the incentive spirometer's role in lung expansion.
C. This outcome measures the client's ability to use the device correctly but does not assess the effectiveness of the device in improving lung function. This outcome is important but does not directly address the goal of the incentive spirometer.
D. This outcome measures compliance with the therapy but does not assess its effectiveness in improving lung function. This outcome is important for adherence but does not directly address the goal of the incentive spirometer.

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The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["31"]

Explanation

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Correct Answer is A

Explanation

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