Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Place the head of the client's bed in the flat position.
Placing the head of the client's bed in the flat position is contraindicated after a thyroidectomy due to the risk of compromising the airway and causing respiratory distress. The head of the bed should be elevated to semi-Fowler's position to promote comfort and reduce swelling.
B. Instruct the client to deep breathe every 4 hr.
Correct. Instructing the client to deep breathe every 4 hours is important for preventing respiratory complications and maintaining lung function after surgery. This helps prevent atelectasis and pneumonia.
C. Hyperextend the client's neck.
Hyperextending the client's neck is contraindicated after a thyroidectomy, as it can put tension on the suture line and potentially cause bleeding or damage to the surgical site. The neck should be maintained in a neutral or slightly flexed position.
D. Check the client's voice every 2 hr.
Checking the client's voice every 2 hours is not a necessary intervention. While assessing vocal cord function is important, checking it this frequently may cause unnecessary disruption to the client's rest and recovery. It is generally assessed less frequently unless there are specific concerns about vocal cord function.
This question is an excerpt from Nurse Dive's nursing test bank - RN ATI Medsurg Proctored Exam. Take the full exam now
Full 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.
Similar Questions
Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following?
A. Sore throat
Correct. Propylthiouracil (PTU) is an antithyroid medication used to treat hyperthyroidism, including Graves' disease. It can sometimes cause agranulocytosis, a condition characterized by a severe reduction in white blood cells, which can lead to symptoms like a sore throat and fever. These symptoms should be reported immediately.
B. Constipation
Constipation is not a common side effect of propylthiouracil. If it occurs, it is usually not an urgent concern, and can often be managed with dietary and lifestyle changes.
C. Increased urine output
Increased urine output is not typically associated with propylthiouracil. It is more likely to be seen with diuretic medications or conditions like diabetes.
D. Painful, excessive menstruation
Painful, excessive menstruation is not a direct side effect of propylthiouracil. However, hormonal changes related to hyperthyroidism can affect menstrual patterns. If the client is experiencing significant changes in menstrual bleeding, it should be reported to the healthcare provider, but it may not be considered an immediate emergency.
Full Explanation
A. Correct. Propylthiouracil (PTU) is an antithyroid medication used to treat hyperthyroidism, including Graves' disease. It can sometimes cause agranulocytosis, a condition characterized by a severe reduction in white blood cells, which can lead to symptoms like a sore throat and fever. These symptoms should be reported immediately.
B. Constipation is not a common side effect of propylthiouracil. If it occurs, it is usually not an urgent concern, and can often be managed with dietary and lifestyle changes.
C. Increased urine output is not typically associated with propylthiouracil. It is more likely to be seen with diuretic medications or conditions like diabetes.
D. Painful, excessive menstruation is not a direct side effect of propylthiouracil. However, hormonal changes related to hyperthyroidism can affect menstrual patterns. If the client is experiencing significant changes in menstrual bleeding, it should be reported to the healthcare provider, but it may not be considered an immediate emergency.
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. Glucocorticoid medications
Glucocorticoid medications are not the primary treatment for diabetic ketoacidosis (DKA). They may be used in specific situations, but they are not the first-line treatment.
B. Oral hypoglycemic medications
Oral hypoglycemic medications are not appropriate for a client with DKA. DKA is a serious condition that requires prompt treatment with insulin and intravenous fluids.
C. Dextrose 5% in 0.45% sodium chloride
Dextrose 5% in 0.45% sodium chloride is not the initial treatment for DKA. This solution contains dextrose, which would raise the blood glucose levels, but it does not provide the necessary insulin to address the underlying issue of insulin deficiency.
D. 0.9% sodium chloride
Correct. The initial treatment for DKA involves administering intravenous fluids, typically with 0.9% sodium chloride (normal saline). This helps to restore blood volume, correct electrolyte imbalances, and gradually lower the high blood glucose levels. Insulin is also administered concurrently to address the underlying insulin deficiency.
Full Explanation
A. Glucocorticoid medications are not the primary treatment for diabetic ketoacidosis (DKA). They may be used in specific situations, but they are not the first-line treatment.
B. Oral hypoglycemic medications are not appropriate for a client with DKA. DKA is a serious condition that requires prompt treatment with insulin and intravenous fluids.
C. Dextrose 5% in 0.45% sodium chloride is not the initial treatment for DKA. This solution contains dextrose, which would raise the blood glucose levels, but it does not provide the necessary insulin to address the underlying issue of insulin deficiency.
D. Correct. The initial treatment for DKA involves administering intravenous fluids, typically with 0.9% sodium chloride (normal saline). This helps to restore blood volume, correct electrolyte imbalances, and gradually lower the high blood glucose levels. Insulin is also administered concurrently to address the underlying insulin deficiency.
The nurse is reviewing a teaching tool created for insulin therapy Which statement on the tool should be corrected? Select all that apply.
A. NPH insulin may be mixed with pens
NPH insulin may be mixed with pens. This statement is correct. NPH insulin can be mixed with other insulins, and it is available in pens for ease of administration.
B. insulin detemir is administered to taking meals
Insulin detemir is administered once or twice daily, not necessarily with meals. Detemir is a long-acting insulin and can be taken once or twice daily, depending on the individual's specific treatment plan. It does not need to be strictly timed with meals.
C. insulin glargine may be used to treat gestational diabetes
Insulin glargine is a long-acting insulin and is generally not used as a first-line treatment for gestational diabetes. Short-acting insulins are typically recommended. Gestational diabetes is usually managed with short-acting insulins (like regular insulin) due to their faster onset and shorter duration of action. Long-acting insulins like glargine are not typically used in this context.
D. Regular insulin can be administered intravenously
Regular insulin can be administered intravenously. This is a correct statement. Regular insulin can indeed be given intravenously in a hospital setting for precise control of blood glucose levels.
E. Lispro is a rapid acting insulin
Lispro is a rapid acting insulin. This statement is accurate. Lispro is a rapid-acting insulin analog used to control high blood sugar levels during and after meals. It has a fast onset of action.
Full Explanation
A. NPH insulin may be mixed with pens. This statement is correct. NPH insulin can be mixed with other insulins, and it is available in pens for ease of administration.
B. Insulin detemir is administered once or twice daily, not necessarily with meals. Detemir is a long-acting insulin and can be taken once or twice daily, depending on the individual's specific treatment plan. It does not need to be strictly timed with meals.
C. Insulin glargine is a long-acting insulin and is generally not used as a first-line treatment for gestational diabetes. Short-acting insulins are typically recommended. Gestational diabetes is usually managed with short-acting insulins (like regular insulin) due to their faster onset and shorter duration of action. Long-acting insulins like glargine are not typically used in this context.
D. Regular insulin can be administered intravenously. This is a correct statement. Regular insulin can indeed be given intravenously in a hospital setting for precise control of blood glucose levels.
E. Lispro is a rapid-acting insulin. This statement is accurate. Lispro is a rapid-acting insulin analog used to control high blood sugar levels during and after meals. It has a fast onset of action.