A nurse is caring for a client who has Graves' disease and is experiencing a thyroid storm. Which of the following actions is the nurse's priority?
Provide a cooling blanket.
Monitor the client's cardiac rhythm.
Administer 0.9% sodium chloride IV.
Obtain the client's blood glucose.
The Correct Answer is B
A. While a cooling blanket may be indicated to reduce fever associated with a thyroid storm, the priority lies in monitoring the cardiac rhythm for potential life-threatening complications such as tachycardia or arrhythmias.
B. Thyroid storm can precipitate severe cardiac complications, making continuous monitoring of the client's cardiac rhythm imperative to detect any abnormalities promptly.
C. Administering IV fluids may be necessary to address dehydration, but it is not the priority over monitoring the cardiac rhythm.
D. While monitoring blood glucose levels is important, it is not the immediate priority in managing a thyroid storm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While determining if the procedure is medically necessary is important, the decision-making process should involve the client's designated surrogate, especially when the client is unable to make decisions.
B. While family support is valuable, the primary concern is ensuring that the client's designated surrogate, who is responsible for making healthcare decisions on behalf of the client, is informed and involved in the decision-making process.
C. Sending the unsigned informed consent form to the facility's risk manager does not address the immediate need to ensure that the client's healthcare surrogate is informed about the procedure and its implications.
D. When a client is unable to provide informed consent due to incapacitation, the nurse should communicate with the client's designated health care surrogate to ensure they are aware of the risks and benefits of the procedure and can make decisions on behalf of the client.
Correct Answer is D
Explanation
A. Chronic kidney disease often results in metabolic acidosis, leading to decreased bicarbonate levels rather than increased.
B. Chronic kidney disease commonly leads to hyperphosphatemia and hypocalcemia due to impaired renal excretion of phosphate and decreased activation of vitamin D, resulting in decreased calcium levels.
C. Chronic kidney disease often results in anemia due to decreased production of erythropoietin, leading to decreased hemoglobin levels rather than increased.
D. Increased creatinine levels are indicative of impaired renal function, a hallmark of chronic kidney disease.
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