A nurse is caring for a 59-year-old male client in the intermediate care unit.

Exhibits
Which of the following findings requires the nurse's immediate attention?

Oxygen saturation of 56%

Crackles heard in the right lung

pH of 7.21

Tracheal deviation to the right

Answer and Explanation

Correct Answer : A,D

Choice A rationale: Oxygen saturation of 56% is critically low and indicates severe hypoxemia, which requires immediate intervention to improve oxygenation and prevent life-threatening complications.

Choice D rationale: Tracheal deviation to the right suggests a possible tension pneumothorax, which is a medical emergency. It requires immediate attention to relieve the pressure on the affected lung and restore normal breathing.

Choice B rationale: Crackles heard in the right lung indicate fluid or atelectasis but are not immediately life-threatening compared to the other findings.

Choice C rationale: A pH of 7.21 indicates acidemia and respiratory acidosis but is a secondary concern compared to the immediate need to address the client's hypoxemia and potential tension pneumothorax.

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

Calcium carbonate is a common medication used to manage low calcium levels, but in clients with hyperparathyroidism, it can exacerbate hypercalcemia, leading to dangerous levels of calcium in the blood. Hyperparathyroidism already causes increased calcium release from bones, increased absorption from the intestines, and decreased excretion by the kidneys, so adding calcium carbonate can worsen these effects, potentially leading to complications like kidney stones, bone pain, and cardiovascular issues. Careful monitoring and possible dose adjustments or discontinuation might be necessary.

Choice B rationale

Acetaminophen is an analgesic and antipyretic commonly used for pain relief and fever reduction. It is metabolized primarily in the liver and does not significantly impact calcium levels or parathyroid hormone function. Therefore, it does not pose an immediate concern for clients with hyperparathyroidism and can typically be used safely without requiring further discussion with the healthcare provider unless there are other contraindications or hepatic issues in the client's medical history.

Choice C rationale

Hydrochlorothiazide is a thiazide diuretic often used to manage hypertension and edema. It reduces urine calcium excretion, which can lead to increased serum calcium levels, exacerbating hypercalcemia in clients with hyperparathyroidism. Thiazide diuretics promote calcium reabsorption in the distal convoluted tubules of the kidneys, potentially worsening the hypercalcemia caused by hyperparathyroidism. Therefore, the use of hydrochlorothiazide should be carefully evaluated and potentially avoided in these clients.

Choice D rationale

Lithium carbonate is used to treat bipolar disorder and can affect parathyroid function, leading to increased parathyroid hormone (PTH) levels and hypercalcemia. Lithium can alter the set point of the calcium-PTH feedback loop, leading to increased release of PTH, even at normal calcium levels. This can result in worsening hyperparathyroidism and hypercalcemia, making it a medication that requires careful consideration and monitoring in affected clients.

Choice E rationale

A. Ask the mother what she usually uses on the child's lips and nose. B. Use a topical lidocaine analgesic for cracked lips. C. Apply a petroleum jelly to the child's nose and lips. D. Use a water-soluble lubricant on affected oral and nasal mucosa.

Correct Answer is D

Explanation

Choice A rationale

Asking the mother about usual care practices might provide useful information, but it is not the best immediate intervention for addressing the child's dry and cracked lips and nares. Immediate action should be taken to provide relief.

Choice B rationale

Using a topical lidocaine analgesic is not appropriate for treating dryness and cracking of the lips and nares. Lidocaine is an anesthetic, not a moisturizing agent, and could cause additional irritation or adverse reactions if used improperly.

Choice C rationale

Applying petroleum jelly to the child's nose and lips is not recommended as it poses a risk of aspiration, especially in young children. Inhaling petroleum jelly can lead to respiratory issues and is therefore not a safe option.

Choice D rationale

Using a water-soluble lubricant is the best option for moisturizing and protecting the child's dry and cracked lips and nares. Water-soluble lubricants are safe for use on mucous membranes and provide effective relief without the risk of aspiration.

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A nurse is caring for a 59-year-old male client in the intermediate care unit. Exhibits Which of the following findings requires the nurse's immediate attention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is managing the care for a client with hyperparathyroidism and is reviewing the client's list of prescribed and over-the-counter medications. Which medication(s) on the client's current medication record should the nurse discuss further with the healthcare provider? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Correct Answer is D

Explanation

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A nurse is caring for a 59-year-old male client in the intermediate care unit.

Exhibits
Which of the following findings requires the nurse's immediate attention?