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 B
Explanation
A. The palms of the hands are less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.
B. Jaundice is characterized by the yellowing of the skin and eyes due to high levels of bilirubin in the blood. In individuals with dark skin, this yellowing may not be as apparent on the skin itself, making the sclera a more accurate site for assessment.
C. The shoulders are less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.
D. The face is less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
A. Clamping the chest tube during ambulation can lead to increased intrathoracic pressure, which may cause tension pneumothorax or other complications. Chest tubes should remain unclamped to maintain proper drainage. However, it may be done briefly during tube changes or if there is a suspected air leak, always under specific medical orders.
B. Burning pain in the chest could indicate complications such as infection or irritation at the insertion site. Reporting this symptom to the provider allows for timely assessment and intervention.
C. A loose dressing around the chest tube can compromise the integrity of the system, leading to air leaks or contamination. Reinforcing the dressing helps maintain a sterile environment and prevents dislodgement of the tube.
D. Maintaining the appropriate water seal level in the chest drainage system is essential for proper functioning. This prevents air from entering the pleural space while allowing drainage to occur effectively.
E. Stripping or milking the chest tube is no longer a recommended practice as it can cause damage to the tissues and lead to airway obstruction or clot formation. Instead, gentle manipulation or rotation of the tubing may be done if there are signs of occlusion, but routine stripping is not recommended
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