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 B

Explanation

Choice A reason: Increasing the rate of the transfusion to complete it as quickly as possible is not safe. Blood transfusions should be completed within four hours to prevent complications such as bacterial contamination and hemolysis.

Choice B reason: Stopping the transfusion immediately and documenting the amount infused is the appropriate intervention. Blood products that have been transfusing for more than four hours must be stopped to ensure patient safety and prevent adverse reactions. Documentation ensures that the healthcare team is aware of the situation and can take appropriate follow-up actions.

Choice C reason: Continuing the transfusion and monitoring vital signs every 15 minutes is not appropriate after the four-hour window has passed. The risk of complications increases with prolonged transfusion times.

Choice D reason: Continuing the transfusion at the current rate until it is completed is not safe. The transfusion must be stopped after four hours to prevent potential complications.

A. Ondansetron on a PRN basis B. Vitamin B12 injections to prevent pernicious anemia C. Antidiarrheal medications 30 minutes before a meal D. Beta adrenergic blockers to reduce bowel motility

Correct Answer is A

Explanation

Choice A reason: Ondansetron is an antiemetic given to control nausea and vomiting, which are common symptoms in patients with inflammatory bowel disease, especially when they have a flare-up.

Choice B reason: Vitamin B12 injections are crucial for preventing pernicious anemia but are not specific treatments for acute management of inflammatory bowel disease symptoms.

Choice C reason: Antidiarrheal medications should be used cautiously in inflammatory bowel disease as they can worsen symptoms or lead to complications like toxic megacolon.

Choice D reason: Beta-adrenergic blockers are not used to reduce bowel motility and are not a part of the standard treatment regimen for inflammatory bowel disease.

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Naxlex Comprehensive Predictor Exams

The nurse is monitoring a patient who is receiving a blood transfusion. The nurse identifies that the blood transfusion started over four hours ago. What intervention will the nurse implement next?

Correct Answer is B

Explanation

The nurse is assessing a patient who is diagnosed with inflammatory bowel disease and is requiring inpatient treatment at a hospital. What medication will the nurse provide when caring for this patient?

Correct Answer is A

Explanation

The nurse is caring for a patient with multiple sclerosis (MS) who is experiencing changes to their bowel function. What intervention will the nurse implement for this patient?

The nurse is caring for a patient with diabetes who presents with a hyperglycemic emergency. The patient's lab values are in the chart below. Which healthcare provider's (HCP) order will the nurse implement?

The nurse is caring for a patient receiving chemotherapy who is admitted with an absolute neutrophil count (ANC) of 459 cells/ulu. The healthcare provider orders G-CSF (filgrastim). Which action will the nurse take to promote safe and effective use of filgrastim for this patient?

The nurse is admitting an older adult with heart failure to the cardiac unit. The nurse notes dyspnea on exertion, fatigue, and 3+ pitting edema in the ankles. What priority actions will the nurse implement for this patient?

The nurse is caring for a patient who is dyspneic with accessory muscle use, respiratory rate 24 breaths/minute, pulse oximetry 88% on room air, and speaking in phrases. When choosing an oxygen delivery system, which guideline is the most appropriate?

The nurse is caring for a patient who is lethargic and dehydrated. Arterial blood gas (ABG) results show pH 7.50, PaO2 85 mmHg, PaCO2 45 mmHg, HCO3 35 mEq/L. What acid-base imbalance will the nurse recognize the patient is at risk for?

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