At 8 a.m. the nurse is reviewing patient assignments and notes one of the patients has a current blood glucose of 264. Breakfast is routinely served at 8:30. The following orders are noted in the chart. What action should the nurse take? Accucheck before meals and at bedtime with sliding scale insulin aspart SQ: Glucose 0-150 Administer 0 units; 151-200 Administer 2 units; 201-250 Administer 4 units: 251-300 Administer 6 units: 301-350 Administer 8 units; 351- 400 Administer 10 units; >400 Notify physician.

Provide 2 units insulin aspart 50

Provide 6 units insulin aspart 50

Provide 10 units insin apart SQ

Provide 4 units insulin aspart 50

Answer and Explanation

The Correct Answer is B

A. This option corresponds to the blood glucose range of 151-200. However, the patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 2 units would not be appropriate in this case.

B. The patient's current blood glucose level is 264, which falls into the range of 251-300. According to the sliding scale insulin aspart orders, for this range, 6 units should be administered. This option aligns with the patient's blood glucose level and the prescribed protocol.

C. This option corresponds to the blood glucose range of 351-400. The patient's blood glucose level of 264 does not fall into this range, so administering 10 units would be excessive and potentially lead to hypoglycemia.

D. This option corresponds to the blood glucose range of 201-250. The patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 4 units would not be sufficient to address the elevated blood glucose level.

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Correct Answer is A

Explanation

A. Correct. Chvostek's sign is a clinical sign of hypocalcemia. It is elicited by tapping on the facial nerve, just anterior to the ear, and observing for facial twitching or spasm.

B. Incorrect. Kernig's sign is a test for assessing meningitis and involves flexing the hip and knee at 90-degree angles and then extending the knee. This test is not relevant to the client's reported symptoms.

C. Incorrect. Brudzinski's sign is another test for assessing meningitis. It involves flexing the neck forward and observing for involuntary flexion of the hips and knees. This test is not relevant to the client's reported symptoms.

D. Incorrect. Babinski's sign is used to assess upper motor neuron lesions. It involves stimulating the sole of the foot, and in a positive response, the big toe extends upward. This test is not relevant to the client's reported symptoms.

A. Place the head of the client's bed in the flat position. B. Instruct the client to deep breathe every 4 hr. C. Hyperextend the client's neck. D. Check the client's voice every 2 hr.

Correct Answer is D

Explanation

- Choice A Rationale: Placing the head of the bed in the flat position is not recommended as it can increase the risk of airway obstruction and reduce venous drainage from the head, which is especially critical after thyroid surgery.
- Choice B Rationale: While deep breathing is important postoperatively, it is not specific to thyroidectomy care and should be done more frequently than every 4 hours to ensure adequate ventilation and prevent atelectasis.
- Choice C Rationale: Hyperextending the client's neck can be harmful post-thyroidectomy as it may put stress on the surgical site, potentially leading to dehiscence or damage to the area.
- Choice D Rationale: Checking the client's voice every 2 hours is essential after a thyroidectomy because vocal cord paralysis can be an indicator of recurrent laryngeal nerve damage, which is a potential complication of the surgery. Monitoring the voice allows for early detection and intervention.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?

Correct Answer is A

Explanation

A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is reviewing the laboratory results for four clients. The nurse should recognize which of the following clients has a manifestation of hypoparathyroidism?

The nurse is reviewing a teaching tool created for insulin therapy Which statement on the tool should be corrected? Select all that apply.

A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.)

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?

A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?

A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

When preparing to provide morning medications, the nurse would give levothyroxine (Synthroid) ordered daily in which of the following ways?