A nurse assesses a patient with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the patient's level of consciousness has decreased. What action does the nurse perform?
Restricts oral intake.
Monitor blood pressure every 4 hours.
Administer SQ insulin as prescribed.
Maintain a patent airway.
The Correct Answer is D
A decrease in the level of consciousness is a serious sign and could be an indication of worsening conditions. It is essential for the nurse to ensure that the patient's airway is open and clear, as a compromised airway can lead to hypoxia and a further decrease in consciousness. Therefore, maintaining a patent airway should be the nurse's priority action in this situation.
While monitoring blood pressure and restricting oral intake may be important interventions in certain situations, they are not the priority actions in this scenario. Administering SQ insulin may not be necessary for a patient with hypothyroidism and acute appendicitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should quickly assess the patient's vital signs to check for signs of shock and instability. If the vital signs are unstable, the nurse should initiate appropriate interventions to stabilize the patient, such as administering oxygen, starting IV fluids, and providing continuous cardiac monitoring. Based on the sudden onset of severe upper abdominal pain, diaphoresis, and a firm abdomen, the nurse should suspect a possible perforation or bleeding related to the peptic ulcer. This is a medical emergency that requires immediate intervention. Therefore, the nurse should prioritize notifying the healthcare provider and preparing the patient for urgent medical evaluation.
Option A, irrigating the NG tube, is not appropriate in this situation and may further exacerbate the patient's condition if the ulcer has perforated.
Option B, elevating the foot of the bed, is also not appropriate as it does not address the patient's current symptoms.
Option C, giving the ordered antacid, may not be effective in addressing the severity of the patient's symptoms and should be postponed until the healthcare provider has evaluated the patient.
Correct Answer is B
Explanation
The patient received 38 U of NPH insulin at 7:00 AM, and by 1:00 PM, the insulin has been active for approximately 6 hours. The patient has missed lunch, which may lead to hypoglycemia, especially with the activity of the insulin.
Sending a glass of orange juice will provide the patient with a quick source of glucose to prevent hypoglycemia. If testing is further delayed, the nurse may request that the patient be allowed to eat lunch first or save the lunch tray for later, but immediate intervention is necessary to prevent hypoglycemia. Discontinuing the evening dose of insulin is not an appropriate action and should not be considered without consulting the healthcare provider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today