The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?

Administer IV fluid bolus as prescribed by the healthcare provider.

Encourage the client to splint the Incision with a pillow to cough and deep breathe.

Medicate for pain and monitor vital signs according to protocol.

Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.

Answer and Explanation

The Correct Answer is C

C.Although postoperative pain can cause a similar presentation, pain management is not the priority intervention.

D. The client's vital signs of tachycardia, tachypnea, and elevated blood pressure suggest potential respiratory distress or inadequate oxygenation following the thoracotomy. Applying oxygen at a high flow rate via a non-rebreather mask can help improve oxygenation and support the client's respiratory function.

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Correct Answer is D

Explanation

D. Palpitations (rapid or irregular heartbeats) and shortness of breath are classic symptoms of hyperthyroidism, indicating an excess of thyroid hormone.
A. Bradycardia (slow heart rate) and constipation are symptoms commonly associated with hypothyroidism, rather than hyperthyroidism. If the dosage of levothyroxine is too high, it would lead to symptoms of hyperthyroidism, not hypothyroidism.
B. Lethargy (fatigue) and lack of appetite are classic symptoms of hypothyroidism. If the dosage of levothyroxine is too high, it can lead to excessive thyroid hormone levels, resulting in symptoms resembling hypothyroidism.
C. Muscle cramping and dry, flushed skin are symptoms commonly associated with hyperthyroidism, which occurs when thyroid hormone levels are too high. Therefore, these symptoms are more indicative of inadequate thyroid hormone levels rather than an overdose of levothyroxine.

A. Use a space heater to keep the workspace warm. B. Take a multivitamin that contains vitamin D daily. C. Keep both hands elevated during work breaks. D. Obtain a keyboard designed to limit wrist flexion.

Correct Answer is A

Explanation

A. Raynaud's syndrome is characterized by vasospasm of the small arteries, often triggered by exposure to cold temperatures or stress. Keeping the workspace warm can help prevent vasospasm and reduce the risk of Raynaud's attacks while the client is working. Using a space heater or adjusting the office temperature can help maintain a comfortable environment for the client.
B. While vitamin D supplementation may have various health benefits, it is not specifically indicated for managing Raynaud's syndrome.
C. Elevating the hands during work breaks may help reduce swelling or discomfort associated with certain conditions, but it is not a specific recommendation for managing Raynaud's syndrome. Elevating the hands may not address the underlying issue of reduced blood flow to the fingers that occurs during Raynaud's attacks.
D. Limiting wrist flexion may help reduce strain on the wrists and hands but would not directly address the symptoms of Raynaud's syndrome related to blood flow. While ergonomic keyboards can be beneficial for preventing repetitive strain injuries and improving comfort during typing, they are not specifically indicated for managing Raynaud's syndrome.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

Correct Answer is D

Explanation

A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?

Correct Answer is A

Explanation

Patient Data Exhibits Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.

Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Patient’s Data Exhibits Select the 3 dietary choices that are not part of the recommended diet gout.

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?