A client receiving thyroid replacement therapy following a thyroidectomy is seen in the dinic for a 6 weeks postoperative check-up. Which assessment is most important for the nurse to obtain?

Report of bowel functioning since surgery.

Heart rate and body weight.

Number of any missed doses of medication.

Daily caloric intake.

Answer and Explanation

The Correct Answer is B

A.   While bowel function can be affected by medication, it's not a primary indicator of thyroid hormone replacement effectiveness.
B.   These are the most important assessments to determine the effectiveness of thyroid replacement therapy. Thyroid hormones influence metabolic rate, which directly affects heart rate and body weight. Changes in these parameters can indicate under- or over-replacement of thyroid hormones.
C.   While medication adherence is important, it doesn't directly assess the medication's effectiveness.
D.   Dietary intake is important for overall health but is not directly related to thyroid hormone replacement therapy effectiveness.

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Correct Answer is []

Explanation

Potential Condition
Poor healing of stage 2 pressure injury
The stage 2 pressure injury on the right trochanter with minimal drainage and pain suggests poor healing, which is often due to a combination of factors including immobility, malnutrition, and other risk factors. The Braden Scale score reflects several high-risk areas that contribute to the poor healing of the pressure injury.
Actions to Take

1. Apply pressure reduction mattress to bed
A pressure reduction mattress helps alleviate pressure on vulnerable areas and can significantly reduce the risk of further injury and promote healing. It is a crucial intervention for managing pressure injuries and preventing new ones.
2. Request service of wound care nurse
Consulting a wound care nurse can provide specialized assessment and treatment for the pressure injury. This professional can recommend advanced wound care techniques and products to support optimal healing and address any complications.
Parameters to Monitor

1. Progression of wound
Monitoring the progression of the wound involves assessing changes in size, depth, and appearance of the pressure injury. This helps evaluate the effectiveness of interventions and the rate of healing.
2. Adherence to repositioning schedule

Regular repositioning is crucial to relieve pressure on vulnerable areas and prevent further injury. Ensuring that the client is repositioned according to the schedule helps prevent pressure ulcers from worsening and supports healing.
Incorrect conditions

Immobility: Although immobility is a factor in pressure injuries, the direct intervention would be to improve mobility, not necessarily apply to the current situation.
Dehydration: While dehydration can affect skin health and healing, the primary condition here is the poor healing of the pressure injury rather than dehydration itself.
Malnutrition: Malnutrition can impair wound healing, but the immediate action would be more related to wound care and pressure relief. Nutrition might be addressed separately through dietary interventions.

A. Place pillows around the bed rails to provide padding. B. Watch the seizure activity and document the time and client movement. C. Manually ventilate the client with a bag-valve mask (BVM). D. Stop the IV fluids. E. Increase the supplemental oxygen to 10 L/minute via nasal cannula. F. Begin chest compressions.

Correct Answer is ["B","C","E"]

Explanation

A. This is important to prevent injury but is not the priority at this time.
B. This is important for monitoring the seizure progression and for providing information to the healthcare provider. However, it should be done while simultaneously performing the more critical interventions of ventilation and oxygenation.
C. This is the highest priority as the client is experiencing respiratory failure with a respiratory rate of 4 breaths/minute. Providing artificial ventilation is crucial to oxygenate the patient.
D. This is not necessary at this point and may not be feasible during the emergency situation.
E. While not as immediate as BVM ventilation, increasing oxygen delivery is essential to improve oxygenation levels.
F. Begin chest compressions: Chest compressions are indicated for cardiac arrest, not respiratory failure.

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A client receiving thyroid replacement therapy following a thyroidectomy is seen in the dinic for a 6 weeks postoperative check-up. Which assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

Correct Answer is ["B","C","E"]

Explanation

The nurse assists a client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

A client is scheduled for a scleral buckling procedure after previously having multiple laser coagulation procedures done for retinal tears. Which Information about the immediate postoperative period should the nurse provide this client?

When learning to use an insulin pen, a client with diabetes dials 28 units of regular insulin instead of 24 units, the prescribed dose. Which action should the nurse take?

A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?

The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "Imbalanced nutrition, less than body requirements." Which cause is most likely contributing to the problem?

The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?