The nurse has reviewed the Vital Signs at 1000.

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"}}

• Apply cooling blanket: The client has an elevated temperature (38.3°C/100.9°F), which could suggest early signs of thyroid storm, a life-threatening complication after thyroid surgery. Applying a cooling blanket is an appropriate non-pharmacological intervention to help manage hyperthermia without medications that could worsen symptoms.

• Monitor vital signs every 4 hours: Frequent monitoring of vital signs is critical after thyroidectomy to detect early signs of complications such as thyroid storm, hemorrhage, or airway compromise. Vital sign changes can provide early warning signs of clinical deterioration and allow for rapid intervention.

• Place client on telemetry: Thyroid storm and other thyroid-related crises can cause arrhythmias, including tachycardia and atrial fibrillation. Continuous cardiac monitoring is anticipated to quickly detect and manage any rhythm disturbances that may arise postoperatively.

• Palpate thyroid area to assess for hematoma: After a thyroidectomy, it is essential to assess for hematoma formation, as hematomas can compress the airway and become life-threatening. Regular palpation of the surgical site helps detect swelling, firmness, or respiratory distress early.

• Administer aspirin for fever: Aspirin is not recommended for fever management in postoperative thyroidectomy clients because it can displace thyroid hormones from binding proteins, potentially worsening thyrotoxicosis. Fever should be managed with other antipyretics like acetaminophen or physical cooling methods instead.

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Correct Answer is C

Explanation

A. Erythema: Erythema, or redness, is more commonly associated with phlebitis, an inflammation of the vein, rather than infiltration. While some redness may occur, it is not the primary or expected finding when infiltration is present.

B. Blood: The presence of blood at the insertion site may indicate a bleeding or hematoma issue but is not a typical sign of infiltration. Infiltration involves fluid, usually IV solution, leaking into surrounding tissue, not blood leaking out of the vein.

C. Edema: Edema at the insertion site is a hallmark sign of infiltration. When IV fluid escapes into the surrounding tissue instead of remaining in the vein, it causes localized swelling, coolness, and often discomfort or tightness around the insertion area.

D. Pruritus: Pruritus, or itching, is not a typical manifestation of infiltration. It may be seen with allergic reactions to IV medications or materials, but infiltration primarily presents with swelling, coolness, and sometimes blanching of the skin.

A. A client who has a urinary tract infection B. A client who has a spinal cord injury C. A client who has acute appendicitis D. A client who has a torn rotator cuff

Correct Answer is B

Explanation

A. A client who has a urinary tract infection: A urinary tract infection is generally straightforward to manage with antibiotics and does not usually require input from multiple disciplines unless complications arise.

B. A client who has a spinal cord injury: A spinal cord injury often involves complex care needs requiring input from several disciplines, including physical therapy, occupational therapy, nursing, social work, and nutrition services. Coordinated planning is essential to optimize recovery and long-term management.

C. A client who has acute appendicitis: Acute appendicitis typically requires prompt surgical intervention but does not usually require an interprofessional conference unless there are unusual complications or comorbidities.

D. A client who has a torn rotator cuff: A torn rotator cuff is typically managed with surgical repair or physical therapy. While it may involve multiple providers, it generally does not require a full interprofessional conference unless extensive rehabilitation needs are anticipated.

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The nurse has reviewed the Vital Signs at 1000. 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 collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?

Correct Answer is C

Explanation

A nurse is assisting with the plan of care for a group of clients. Which of the following clients should the nurse recommend for an interprofessional conference?

Correct Answer is B

Explanation

A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously. Which of the following adverse effects of the medication should the nurse report to the provider?

The nurse has reviewed the Nurses' Notes and Provider Prescriptions at 1100 and Diagnostic Results on Day 3. The nurse is preparing the client for surgery. Which of the following actions should the nurse take. Select all that apply.

A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

A nurse is documenting client care in the nurses' notes and notices that a space was left blank. Which of the following actions should the nurse take?

A nurse is caring for a client who has a fractured arm in a cast. Which of the following findings about the affected arm should the nurse report to the provider?

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

A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

The nurse has reviewed the Vital Signs at 1000.

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