Question

A nurse is teaching a client who has a new prescription for levothyroxine (T4) about thyrotoxicosis. The nurse should instruct the client to monitor and report which of the following findings?

Answer 1

Correct Answers:

Fever

Rationale :

🧿 Fever can indicate excessive thyroid hormone activity and possible thyrotoxicosis in a client taking levothyroxine.

🧿 Levothyroxine replaces thyroxine (T4), and excessive dosing can produce manifestations similar to hyperthyroidism.

🧿 Excess thyroid hormone increases the body's metabolic rate and heat production, which can cause an elevated temperature.

🧿 Other manifestations of thyrotoxicosis can include tachycardia, palpitations, tremors, nervousness, sweating, and heat intolerance.

🧿 Severe thyrotoxicosis can progress to thyroid storm, which is a potentially life-threatening emergency.

🧿 Thyroid storm may present with high fever, severe tachycardia, hypertension, and altered mental status.

🧿 The client should therefore be instructed to promptly report fever or other manifestations of excessive thyroid hormone activity.

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Answer 2

Correct Answers:

Small clots with tissue in the urine

Rationale :

🍊 Following a transurethral resection of the prostate (TURP), some postoperative bleeding from the surgical site is expected.

🍊 During the early postoperative period, the urine can contain small blood clots and pieces of resected prostatic tissue.

🍊 The client commonly has an indwelling urinary catheter, often with irrigation, to maintain catheter patency and facilitate drainage of blood and tissue.

🍊 Small clots can therefore be an expected postoperative finding as long as urinary drainage remains adequate.

🍊 The nurse should continue monitoring the color, amount, and characteristics of urinary output for evidence of excessive bleeding or obstruction.

🍊 Increasing numbers of clots, reduced urinary output, bladder distention, or worsening suprapubic discomfort can indicate catheter obstruction and require intervention.

🍊 Urine should generally become progressively lighter and clearer as postoperative bleeding decreases.

🍊 Therefore, small clots with tissue in the urine are the expected finding two days following TURP.

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Answer 3

Correct Answers:

Abdominal distention

Rationale :

🌻 Abdominal distention is a characteristic finding of paralytic ileus, which can occur following surgery.

🌻 Paralytic ileus results from a temporary loss or reduction of normal intestinal peristalsis without a mechanical obstruction.

🌻 When intestinal contents and gas cannot move normally through the gastrointestinal tract, they accumulate and cause abdominal distention.

🌻 The client may also experience abdominal discomfort, nausea, vomiting, and inability to pass flatus.

🌻 Assessment commonly reveals hypoactive or absent bowel sounds because intestinal motility is decreased.

🌻 Orthopedic surgery, anesthesia, opioid analgesics, immobility, and electrolyte abnormalities can contribute to postoperative ileus.

🌻 The nurse should monitor the client's abdominal assessment, bowel sounds, passage of flatus, and gastrointestinal symptoms following surgery.

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Answer 4

Correct Answers:

Position the sterile drape leaving the perineum exposed.

Rationale :

🏵️ After establishing the sterile field, the nurse should position the sterile drape so that the client's perineal area is exposed while maintaining sterile technique.

🏵️ The sterile drape creates a protected working area and reduces the risk of contaminating the catheter and sterile supplies.

🏵️ Proper draping occurs before manipulating supplies that will be used during catheter insertion.

🏵️ Once the sterile field is appropriately positioned, the nurse can continue preparing the catheter and other equipment.

🏵️ Lubrication of the catheter occurs after the sterile field has been established and the client has been properly draped.

🏵️ The urinary meatus is then cleansed with the prescribed antiseptic solution immediately before catheter insertion.

🏵️ Maintaining the correct sequence reduces the introduction of microorganisms into the urinary tract and helps prevent catheter-associated urinary tract infection (CAUTI).

🏵️ Therefore, among the listed actions, positioning the sterile drape while leaving the perineum exposed should be performed first.

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Answer 5

Correct Answers:

Nervousness

Rationale :

🧿 A blood glucose level of 64 mg/dL indicates hypoglycemia, which generally occurs when blood glucose falls below 70 mg/dL.

🧿 Nervousness is a common manifestation of hypoglycemia because falling glucose levels stimulate the sympathetic nervous system.

🧿 Sympathetic activation causes the release of epinephrine and other counter-regulatory hormones in an attempt to increase blood glucose.

🧿 Early manifestations can include nervousness, anxiety, tremors, sweating, palpitations, and hunger.

🧿 As hypoglycemia becomes more severe, inadequate glucose delivery to the brain can cause confusion, behavioral changes, seizures, and loss of consciousness.

🧿 Clients with type 1 diabetes mellitus are particularly susceptible to hypoglycemia when insulin intake exceeds available glucose, such as after inadequate food intake or increased activity.

🧿 Recognition of early manifestations is important because untreated hypoglycemia can rapidly progress to neurologic impairment.

🧿 Therefore, nervousness is the expected assessment finding with a blood glucose of 64 mg/dL.

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Answer 6

Correct Answers:

White fish

Rationale :

🌼 White fish is an appropriate dietary choice for a client with gastroesophageal reflux disease (GERD) because it is generally lean and low in fat when prepared without frying or heavy sauces.

🌼 High-fat foods can delay gastric emptying and may decrease lower esophageal sphincter tone, increasing the likelihood of reflux.

🌼 Lean protein sources such as baked, broiled, grilled, or steamed white fish are less likely to trigger GERD symptoms.

🌼 White fish is also non-acidic, making it preferable to acidic foods such as tomatoes and citrus fruits.

🌼 Clients with GERD should select foods that minimize heartburn and regurgitation while still providing adequate nutrition.

🌼 Preparation is important because frying the fish or adding high-fat sauces could increase its potential to trigger reflux symptoms.

🌼 Individual food triggers can vary, so clients should also monitor which foods worsen their personal GERD symptoms.

🌼 Therefore, choosing white fish demonstrates an understanding of appropriate dietary management for GERD.

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Answer 7

Correct Answers:

"You may feel a warm sensation after the dye is injected."

Rationale :

🌸 During intravenous excretory urography, an iodinated contrast medium is administered intravenously to visualize the kidneys, ureters, and urinary bladder on radiographic images.

🌸 Clients commonly experience a temporary warm or flushing sensation when the contrast material is injected.

🌸 The sensation may spread throughout the body and is generally brief and expected.

🌸 The nurse should explain this expected sensation beforehand to decrease anxiety during contrast administration.

🌸 Some clients may also experience a temporary metallic taste during injection of the contrast medium.

🌸 The nurse must distinguish expected warmth from manifestations of a contrast reaction, such as difficulty breathing, wheezing, facial swelling, or severe hypotension.

🌸 Appropriate preparation also includes assessing relevant history and factors that could increase the risk of complications from iodinated contrast.

🌸 Therefore, telling the client that a warm sensation may occur after the dye is injected is appropriate preprocedure teaching.

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Answer 8

Correct Answers:

Select a site proximal to previous venipuncture sites.

Rationale :

📗 When inserting a short peripheral IV catheter, the nurse should generally select a site proximal to a previous venipuncture site when another IV attempt is required.

📗 Using a site proximal to the previous puncture helps prevent IV fluid from leaking through the prior puncture site.

📗 Peripheral IV therapy generally begins with the most distal appropriate vein, preserving more proximal veins for subsequent access if needed.

📗 The nurse should select a vein that is straight, palpable, and appropriate for the prescribed therapy.

📗 Sites over joints or areas of significant movement should be avoided when possible because movement increases the risk of catheter displacement, infiltration, and phlebitis.

📗 The nurse should also use the smallest-gauge catheter capable of safely delivering the prescribed fluids or medications.

📗 Appropriate site and catheter selection reduces complications such as infiltration, extravasation, occlusion, and phlebitis.

📗 Therefore, selecting a site proximal to previous venipuncture sites is the appropriate action.

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Answer 9

Correct Answers:

"I will avoid crushing this medication."

Rationale :

♠️ Metformin extended-release (ER) tablets are formulated to release medication gradually over an extended period.

♠️ The client should swallow the tablet whole rather than crush, chew, or break it unless the specific product instructions permit splitting.

♠️ Crushing an extended-release tablet can disrupt its controlled-release mechanism and cause the medication to be released too rapidly.

♠️ Metformin works primarily by decreasing hepatic glucose production and improving the body's sensitivity to insulin.

♠️ Taking metformin with food can help reduce common gastrointestinal adverse effects, such as nausea, diarrhea, and abdominal discomfort.

♠️ Extended-release metformin is commonly administered once daily with the evening meal, although the client should follow the specific prescription.

♠️ Metformin generally does not promote weight gain and may be associated with modest weight loss or weight neutrality.

♠️ Therefore, stating “I will avoid crushing this medication” demonstrates correct understanding of extended-release metformin administration.

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Answer 10

Correct Answers:

The client's systolic blood pressure decreases by 25 mm Hg.

Rationale :

🌹 Orthostatic hypotension occurs when blood pressure decreases significantly after a client moves from lying to sitting or standing.

🌹 It is generally identified by a decrease in systolic blood pressure of at least 20 mm Hg or a decrease in diastolic blood pressure of at least 10 mm Hg after a positional change.

🌹 A 25 mm Hg decrease in systolic blood pressure exceeds the diagnostic threshold and therefore indicates orthostatic hypotension.

🌹 Antihypertensive medications can increase the risk because they may interfere with the body's ability to maintain adequate blood pressure during position changes.

🌹 Clients may experience dizziness, lightheadedness, weakness, blurred vision, or syncope when the blood pressure falls.

🌹 Orthostatic hypotension also increases the client's risk for falls and injury, particularly when getting out of bed.

🌹 The nurse should assist the client with position changes and encourage slow transitions from lying to sitting and then standing.

🌹 Therefore, a 25 mm Hg decrease in systolic blood pressure is the finding that indicates orthostatic hypotension.

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QLexNursing

1 :
A nurse is teaching a client who has a new prescription for levothyroxine (T4) about thyrotoxicosis. The nurse should instruct the client to monitor and report which of the following findings?

2 :
A nurse is assessing a client who is 2 days postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?

3 :
A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

4 :
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

5 :
A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL (74-106 mg/dL) on the glucometer. Which of the following assessment findings should the nurse expect?

6 :
A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?

7 :
A nurse is providing education to a client who is to undergo an intravenous excretory urography. Which of the following statements should the nurse include when preparing the client for the procedure?

8 :
A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

9 :
A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

QLexNursing

1 : A nurse is teaching a client who has a new prescription for levothyroxine (T4) about thyrotoxicosis. The nurse should instruct the client to monitor and report which of the following findings?

2 : A nurse is assessing a client who is 2 days postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?

3 : A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

4 : A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

5 : A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL (74-106 mg/dL) on the glucometer. Which of the following assessment findings should the nurse expect?

6 : A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?

7 : A nurse is providing education to a client who is to undergo an intravenous excretory urography. Which of the following statements should the nurse include when preparing the client for the procedure?

8 : A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

9 : A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching?

10 : A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

1 :
A nurse is teaching a client who has a new prescription for levothyroxine (T4) about thyrotoxicosis. The nurse should instruct the client to monitor and report which of the following findings?

2 :
A nurse is assessing a client who is 2 days postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?

3 :
A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

4 :
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

5 :
A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL (74-106 mg/dL) on the glucometer. Which of the following assessment findings should the nurse expect?

6 :
A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?

7 :
A nurse is providing education to a client who is to undergo an intravenous excretory urography. Which of the following statements should the nurse include when preparing the client for the procedure?

8 :
A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

9 :
A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?