The nurse is assessing a patient with a history of Graves' disease. The assessment is in the chart below. Which interventions will the nurse include in the plan of care? (Select All That Apply)

Assessment:

Respiratory Rate: 28 breaths/minute

Heart rate: 145 beats/minute and irregular

Temperature: 102.2°F (39°C)

Blood pressure: 167/80 mmHg

Level of consciousness: Decreased

Apply a hypothermia blanket.

Administer humidified oxygen.

Administer aspirin 325 mg orally.

Administer D5NS intravenous infusion.

Administer propylthiouracil.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Applying a hypothermia blanket is appropriate for managing hyperthermia in a patient with Graves' disease. Elevated temperatures (fever) are common in thyroid storm, a severe complication of Graves' disease. Using a hypothermia blanket helps reduce the body temperature and prevent further complications.

Choice B reason: Administering humidified oxygen is important for supporting respiratory function in a patient with increased respiratory rate and decreased level of consciousness. Humidified oxygen can help alleviate respiratory distress and improve oxygenation.

Choice C reason: Administering aspirin 325 mg orally is not recommended for patients with hyperthyroidism or thyroid storm. Aspirin can increase free thyroid hormone levels by displacing thyroid hormone from its binding proteins, potentially worsening the patient's condition. Acetaminophen is a safer alternative for managing fever in these patients.

Choice D reason: Administering D5NS intravenous infusion is appropriate for managing dehydration and electrolyte imbalances in a patient with thyroid storm. This intervention helps maintain fluid balance and provides dextrose for energy.

Choice E reason: Administering propylthiouracil is a key intervention for managing thyroid storm. Propylthiouracil inhibits thyroid hormone synthesis and peripheral conversion of T4 to T3, helping to reduce thyroid hormone levels and alleviate symptoms.

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Correct Answer is ["A","E"]

Explanation

Choice A reason: Eating any foods before dialysis as long as fluid intake is limited is incorrect. Patients undergoing hemodialysis need to follow specific dietary restrictions to manage electrolyte balance and prevent complications. A renal diet typically limits potassium, phosphorus, and sodium intake, in addition to fluid restrictions.

Choice B reason: Reporting any unusual changes in the access site, like redness or swelling, is correct. Changes at the access site can indicate infection or other complications and require immediate attention.

Choice C reason: Checking blood pressure regularly to monitor for changes during dialysis is correct. Blood pressure monitoring is essential during dialysis to detect hypotension or hypertension and adjust treatment accordingly.

Choice D reason: Contacting the healthcare provider if swelling in hands, feet, or ankles is noticed is correct. Swelling can indicate fluid overload or other complications that need to be addressed.

Choice E reason: Understanding that hemodialysis will permanently cure kidney disease is incorrect. Hemodialysis is a treatment that replaces kidney function but does not cure kidney disease. It manages symptoms and removes waste products from the blood.

A. Bronchoconstriction B. Pulmonary edema C. Hemoptysis D. Pneumothorax

Correct Answer is A

Explanation

Choice A reason: Wheezing is a typical sound heard during bronchoconstriction, which occurs in conditions like asthma and COPD. It indicates that the airways are narrowed, causing the characteristic sound.

Choice B reason: Pulmonary edema typically presents with crackles or rales rather than wheezing. Wheezing would not be the primary indication of this condition.

Choice C reason: Hemoptysis refers to coughing up blood and does not typically present with wheezing. It might present with other sounds if there is an underlying lung issue, but wheezing is not specific to it.

Choice D reason: Pneumothorax generally presents with decreased or absent breath sounds on one side, not wheezing. It occurs when air enters the pleural space, causing lung collapse.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching a patient who is scheduled for hemodialysis about the process and potential complications. Which of the following statements by the patient indicates to the nurse the need for further teaching? (Select All That Apply)

Correct Answer is ["A","E"]

Explanation

The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD) who is reporting dyspnea. The nurse auscultates the patient's chest and hears wheezing throughout the lung fields. What does this finding indicate to the nurse about this patient?

Correct Answer is A

Explanation

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