The nurse is admitting a 69-year-old male patient with acute heart failure. The physician has ordered furosemide 80 mg IV stat, digoxin 0.25 mg PO, and potassium chloride 20 mEq PO now. Which assessment finding is most indicative of an ineffective response 2 hours after the administration of all the medications?

Pulse oximetry 96%.

Heart rate of 77, regular.

Trace bilateral ankle edema.

Urine output 60 mL.

Answer and Explanation

The Correct Answer is D

The correct answer is d. Urine output 60 mL.

Choice A reason: A pulse oximetry reading of 96% is within normal limits and does not indicate an ineffective response to the medications.

Choice B reason: A heart rate of 77, regular, is also within normal limits and does not suggest an ineffective response.

Choice C reason: Trace bilateral ankle edema may persist even after effective treatment due to residual effects of heart failure.

Choice D reason: A urine output of 60 mL over 2 hours post-diuretic administration suggests an inadequate response, as furosemide is expected to produce a significant diuresis to reduce fluid overload in acute heart failure.

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Correct Answer is A

Explanation

Choice A reason: A thyroidectomy, which is the surgical removal of the thyroid gland, directly leads to hypothyroidism because the body can no longer produce thyroid hormones. This client is at the greatest risk of developing hypothyroidism.

Choice B reason: While exposure to certain chemicals in pesticides can be a risk factor for thyroid dysfunction, it does not pose as immediate a risk as the removal of the thyroid gland itself.

Choice C reason: Thyroid nodules can be associated with thyroid dysfunction, but not all nodules result in hypothyroidism, and many are benign and asymptomatic.

Choice D reason: Vomiting secondary to influenza is not directly related to the development of hypothyroidism.

A. Temperature 99.6°F B. Skin flushed with capillary refill <3 seconds C. Renal output 45 mL/hr D. Arrhythmias

Correct Answer is D

Explanation

Choice A reason: A temperature of 99.6°F is a mild fever and not specifically indicative of the late phase of septic shock.

Choice B reason: Skin that is flushed with a capillary refill of less than 3 seconds does not suggest the late phase of septic shock, which would typically present with poor perfusion.

Choice C reason: A renal output of 45 mL/hr is within the normal range (0.5-1 mL/kg/hr for adults) and does not necessarily indicate the late phase of septic shock.

Choice D reason: Arrhythmias can be a sign of the late phase of septic shock as they indicate cardiac dysfunction, which is a result of decreased tissue perfusion and can lead to multiple organ failure.

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Naxlex Comprehensive Predictor Exams

The nurse practitioner is assessing clients for their risk of developing hypothyroidism. Which of these clients would the nurse consider at greatest risk?

Correct Answer is A

Explanation

When assessing a client with sepsis, which finding would be consistent with the late phase of septic shock?

Correct Answer is D

Explanation

The nurse is assessing a client diagnosed with Parkinson's disease. Which data would the nurse anticipate? Select all that apply.

The nurse is caring for a client who has just returned to the unit following a thyroidectomy. Which assessment finding is a priority for the nurse to report to the healthcare provider?

A client has the following arterial blood gas (ABG) results: pH 7.51, PaCO2 39 mm Hg, HCO3 32 mEq/L. How would the nurse interpret these results? Normal values: pH: 7.35-7.45, PaCO2: 35-45 mm Hg, HCO3: 22-26 mEq/L

The nurse suspects the client's dose of levothyroxine (Synthroid) is too low when the client displays which symptom?

A client's arterial blood gas (ABG) reads: pH 7.18, PaCO2 54 mm Hg, HCO3 26 mEq/L. What condition does the nurse recognize may contribute to the development of this result? Normal values: pH: 7.35-7.45, PaCO2: 35-45 mm Hg, HCO3: 22-26 mEq/L

The nurse is admitting a client with a thyroid disorder who presents with periorbital edema, cold intolerance, and weight gain. Which intervention should the nurse include in this client's plan of care?