The nurse has reviewed the Vital Signs at 1000.

Exhibits
For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

Administer aspirin for fever

Apply cooling blanket

Monitor vital signs every 4 hours

Place client on telemetry

Palpate thyroid area to assess for hematoma

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Rationale:

• Administer aspirin for fever: Aspirin can increase circulating thyroid hormones by displacing T4 and T3 from protein-binding sites. In a hyperthyroid or recently post-thyroidectomy patient, this may precipitate or worsen a thyroid storm. Acetaminophen is a safer antipyretic choice.

• Apply cooling blanket: The client’s postoperative fever (38.3°C), elevated heart rate (98/min), and history of hyperthyroidism indicate a risk for thyroid storm. External cooling is a supportive measure to manage hyperthermia during this critical period.

• Monitor vital signs every 4 hours: This is anticipated to detect signs of complications such as thyroid storm, hemorrhage, or airway compromise. Postoperative clients require close observation to identify early changes in temperature, pulse, or respiration.

• Place client on telemetry: Cardiac monitoring is essential after thyroidectomy in clients with a history of hyperthyroidism. Increased metabolic demand, fever, and potential for arrhythmias justify continuous cardiac observation.

• Palpate thyroid area to assess for hematoma: A neck hematoma is a potentially life-threatening complication of thyroid surgery. It can lead to airway obstruction. Palpation and inspection for swelling or firmness around the incision site are critical nursing assessments.

Nursing Test Bank

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Rationale:

• Monitor fetal heart rate: Continuous monitoring is essential after epidural placement to detect changes in fetal status. Minimal variability and early decelerations could indicate emerging fetal distress. Early detection guides timely intervention.

• Assist with administration of ampicillin IV: The client is GBS positive and in active labor with ruptured membranes. IV antibiotics reduce the risk of neonatal infection. Prompt administration is key for prophylaxis.

• Request a prescription for ephedrine: Epidural anesthesia may cause maternal hypotension, which decreases placental perfusion. Ephedrine helps maintain blood pressure. This supports uteroplacental circulation and fetal oxygenation.

• Place the client in left lateral position: This improves uterine perfusion and helps relieve vena cava compression. It is especially important after epidural anesthesia. It also supports better fetal oxygenation during decelerations.

• Decrease the IV flow rate: IV fluids help counteract hypotension that may result from epidural use. Reducing the rate would worsen perfusion and blood pressure. This could compromise fetal oxygen delivery.

A. Swelling of the lips B. Nauses C. Hand tremors D. Hyperglycemia

Correct Answer is A

Explanation

Rationale:

A. Swelling of the lips: Swelling of the lips can be an early sign of anaphylaxis, a severe allergic reaction. Epinephrine is the first-line treatment for anaphylaxis because it rapidly reduces airway swelling, improves breathing, and supports blood pressure by constricting blood vessels.

B. Nausea: While nausea may occur during an allergic reaction, it is not a primary life-threatening symptom addressed by epinephrine. Epinephrine targets cardiovascular and respiratory symptoms more directly, not gastrointestinal discomfort.

C. Hand tremors: Tremors are actually a potential side effect of epinephrine due to its stimulation of the sympathetic nervous system. The medication is not intended to treat tremors and may even cause or worsen them temporarily.

D. Hyperglycemia: Epinephrine can increase blood glucose levels as a side effect, but it is not prescribed to treat or manage hyperglycemia. Managing blood glucose is not part of the therapeutic purpose of this emergency medication.

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The nurse has reviewed the Vital Signs at 1000. Exhibits For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is in active labor. Exhibits The nurse is assisting with the care of the client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

Correct Answer is A

Explanation

A nurse is caring for a client who was recently diagnosed with depression. The client's partner asks when he will get better. Which of the following is an appropriate response by the nurse?

A nurse is reinforcing teaching with a 36-year-old client who is at 16 weeks of gestation and is scheduled for an amniocentesis. The nurse should include in the teaching that an amniocentesis is performed to identify which of the following findings?

A nurse is reinforcing teaching with a newly licensed nurse about transcribing medication prescriptions. Which of the following prescriptions should the newly licensed nurse identify is an accurate transcription?

A nurse is reinforcing teaching with a new parent about bathing her newborn. Which of the following statements should the nurse include?

A nurse is assisting with the care of a client who has schizophrenia and is actively hallucinating. Which of the following actions should the nurse take?

A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively? (Select all that apply.)

A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

The nurse has reviewed the Vital Signs at 1000.

Exhibits
For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.