Nursing Elites

1. What is a priority intervention for a patient experiencing a thyroid storm?

• A. Administering antipyretics.
• B. Cooling the patient.
• C. Administering beta-blockers.
• D. Administering antithyroid medications.

Correct answer: D

Rationale: During a thyroid storm, the priority intervention is to administer antithyroid medications to reduce thyroid hormone levels quickly. These medications, such as propylthiouracil or methimazole, help inhibit the production of thyroid hormones. Administering antipyretics (choice A) may help reduce fever, but it does not address the underlying cause of the thyroid storm. Cooling the patient (choice B) may provide symptomatic relief but does not address the thyroid hormone dysregulation. Administering beta-blockers (choice C) can help manage symptoms like tachycardia and hypertension, but it does not target the root cause of the thyroid storm.

2. A client with chronic heart failure is being taught by a nurse about the importance of daily weights. Which of the following instructions should the nurse include?

• A. Weigh yourself at the same time every day.
• B. Use the same scale for weighing each time.
• C. Record your weight in a journal or log.
• D. Report any weight gain of more than 2 to 3 pounds in a day.

Correct answer: D

Rationale: The correct instruction for a client with chronic heart failure is to report any weight gain of more than 2 to 3 pounds in a day. This weight gain may indicate fluid retention, which is a critical sign of worsening heart failure. Weighing at the same time every day and using the same scale for consistency are good practices, but the crucial action is to promptly report significant weight gain, as stated in option D. Recording the weight in a journal or log can be helpful for tracking trends, but immediate reporting of weight gain is essential for timely intervention in heart failure management. Therefore, option D is the most appropriate instruction for this client.

3. A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication that:

• A. The tube is patent
• B. There is probably a kink in the tubing
• C. Suction should be added to the system
• D. The client is retaining airway secretions

Correct answer: A

Rationale: The correct answer is A: 'The tube is patent.' When the fluid in the water seal chamber rises and falls during inspiration and expiration, it indicates that the chest tube is patent, allowing for proper drainage. Choice B is incorrect because a kink in the tubing would obstruct the flow of fluid, leading to abnormal fluctuations in the water seal chamber. Choice C is incorrect as adding suction to the system is not indicated based on the described finding. Choice D is incorrect as the rising and falling of fluid in the water seal chamber is not indicative of the client retaining airway secretions.

4. In a patient with deep vein thrombosis (DVT), which of the following symptoms would be expected?

• A. Chest pain.
• B. Shortness of breath.
• C. Coughing up blood.
• D. Cyanosis.

Correct answer: B

Rationale: Shortness of breath is a common symptom of deep vein thrombosis (DVT) due to the risk of a pulmonary embolism. DVT occurs when a blood clot forms in a deep vein, usually in the legs. If a portion of the clot breaks loose and travels to the lungs, it can cause a pulmonary embolism, leading to symptoms like shortness of breath. Chest pain is more commonly associated with conditions like a heart attack or pulmonary embolism itself. Coughing up blood is a symptom more indicative of conditions such as pulmonary embolism or lung cancer. Cyanosis, which is a bluish discoloration of the skin or mucous membranes due to poor oxygenation, can be seen in severe cases of pulmonary embolism but is not a typical symptom of DVT.

5. A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply.

• A. That informed consent is required
• B. That the test takes about 1 hour to complete
• C. That premedication for sedation may be necessary
• D. That food and fluids will be withheld before the procedure

Correct answer: B

Rationale: The correct answer is that the ERCP procedure takes about 1 hour to complete. Informed consent is required before the procedure. Premedication for sedation may be necessary as sedation is commonly used during ERCP to keep the client comfortable. Food and fluids are withheld before the procedure to prevent aspiration and ensure a clear view during the procedure. Position changes may be necessary to facilitate the passage of the tube.

Similar Questions