A nurse is assisting with the care of a client in a PACU. Provider Prescriptions

1100:

Oxygen 2 to 5 L/min via nasal cannula to maintain oxygen saturation greater than 92%.

Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.

Place the client in the supine position.

Prepare to administer oxygen via Venturi face mask.

Add a humidifier to the oxygen device.

Encourage client to perform deep breathing exercises.

Examine the client's nail beds.

Answer and Explanation

Correct Answer : C,D,E

When managing oxygenation for a client in a PACU, the nurse should take several actions. The nurse should add a humidifier to the oxygen device to help prevent dryness of the nasal passages¹.

The nurse should also encourage the client to perform deep breathing exercises to promote oxygenation¹.

Additionally, the nurse should examine the client's nail beds for signs of cyanosis, which can indicate inadequate oxygenation¹.

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Correct Answer is C

Explanation

Thyrotoxicosis refers to a state of excess thyroid hormone in the body, which can occur as a result of excessive levothyroxine dosage or other causes. Nervousness is a common symptom of thyrotoxicosis, characterized by an excessive or uncontrollable feeling of anxiety or restlessness. It is important for the client to report this symptom to the healthcare provider because it may indicate an imbalance in thyroid hormone levels and may require adjustment of the medication dosage.

Polyuria, which refers to increased urination, is not a specific symptom of thyrotoxicosis. It can occur due to various factors unrelated to thyroid function.

Pruritus, or itching, is not a common symptom of thyrotoxicosis. It may be associated with other conditions or causes.

Cough is not typically associated with thyrotoxicosis. It is more commonly related to respiratory or pulmonary conditions rather than thyroid dysfunction.

A. Hematuria B. Hypertension C. Tinnitus D. Hyperglycemia

Correct Answer is B

Explanation

Tranylcypromine is a monoamine oxidase inhibitor (MAOI) medication used to treat depression. MAOIs inhibit the activity of the enzyme monoamine oxidase, which helps regulate the breakdown of certain neurotransmitters, including tyramine. Tyramine is typically broken down by monoamine oxidase, but when taking an MAOI, the enzyme's inhibition can lead to an excessive accumulation of tyramine in the body.

Tyramine-rich foods, such as aged cheeses, cured meats, and certain fermented or pickled foods, contain high levels of tyramine. Ingesting these foods while taking an MAOI can lead to a sudden release of stored norepinephrine, causing a hypertensive crisis.

Hypertension is a potentially serious adverse effect of MAOI therapy combined with tyramine-rich food ingestion. Symptoms of a hypertensive crisis can include severe headache, palpitations, chest pain, sweating, blurred vision, and in severe cases, it can lead to stroke or other cardiovascular complications.

Hematuria refers to the presence of blood in the urine and is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion.

Tinnitus refers to the perception of ringing or noise in the ears and is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion.

Hyperglycemia, or high blood sugar levels, is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion. However, it's important to note that tranylcypromine may interact with certain diabetes medications, so it's essential to consider the client's overall medical history and potential drug interactions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has hypothyroidism and a new prescription for levothyroxine. The nurse should instruct the client to notify the provider of which of the following manifestations of thyrotoxicosis?

Correct Answer is C

Explanation

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

Correct Answer is B

Explanation

A nurse is caring for a client who speaks a different language than the nurse. The client's partner tells the nurse that the client would like to go home against medical advice (AMA). Which of the following actions should the nurse take?

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss. Which of the following strategies should the nurse include in the plan?

A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?

A nurse is reviewing client confidentiality with other staff members. The nurse should identify that which of the following actions is an example of protecting client confidentiality?

A nurse is reinforcing teaching with a client about collecting a stool specimen to check for occult blood. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. For which of the following adverse eﬀects should the nurse instruct the client to monitor and report to the provider?

A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching?