Answers Part 6

1. Answer B is correct.

The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not cor- rect the problem, making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.


2. Answer C is correct.

C is correct because direct pressure to the nose stops the bleed- ing. Answers A, B, and D are incorrect because they do not stop bleeding.


3. Answer A is correct.

Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other dis- orders; therefore, answers B, C, and D are incorrect.



4. Answer A is correct.

IV glucocorticoids raise the glucose levels and often require cov- erage with insulin. Answer B is not necessary at this time, sodium and potassium lev- els would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are incorrect.

5. Answer B is correct.

The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling can be due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so answers C and D are incorrect.


6. Answer D is correct.

The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.



7. Answer A is correct.

The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis. The medication takes effect within one month of beginning therapy, so answer B is incorrect. The medica- tion should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making answer C incorrect. Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect.


8. Answer B is correct.

Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not Trendelenburg position, as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.



9. Answer C is correct.

A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus, answers A, B, and D are incorrect.


10. Answer C is correct.

Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every six months, not three months, and one tablet should be taken every five minutes until pain subsides, so answers A and B are incorrect. If the pain does not subside, the client should report to the emergency room. The medica- tion should be taken sublingually and should not be crushed, as stated in answer D.