Ignatavicius Chapter 63 (Evolve) questions with
correct answers
An older client with an elevated serum calcium level is receiving IV furosemide (Lasix) and an infusion of normal saline at 150 mL/hr. Which nursing action can the RN delegate to unlicensed assistive personnel (UAP)?
A. Ask the client about any numbness or tingling.
B. Check for bone deformities in the client's back.
C. Measure the client's intake and output hourly.
D. Monitor the client for shortness of breath. Answer ✓✓ C. Measure the client's intake and output hourly.
Measuring hourly intake and output is a commonly delegated nursing action that is within the UAP scope of practice. Numbness and tingling is part of the client assessment that needs to be completed by a licensed nurse. Bony deformities can be due to pathologic fractures. Physical assessment is a complex task that cannot be delegated to a UAP. An older client receiving an IV at 150 mL/hr is at risk for congestive heart failure. Careful monitoring for shortness of breath is the responsibility of the RN.
The nurse manager for the medical-surgical unit is making staff assignments. Which client will be most appropriate to assign to a newly graduated RN who has completed a 6-week unit orientation?
A. Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily
B. Client with follicular thyroid cancer who has vocal hoarseness and difficulty swallowing C. Client with Graves' disease who is experiencing increasing anxiety and diaphoresis
D. Client with hyperparathyroidism who has just arrived on the unit after a parathyroidectomy Answer ✓✓ A. Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily
The client with chronic hypothyroidism and dementia is the most stable of the clients described and would be most appropriate to assign to an inexperienced RN.A client with vocal hoarseness and difficulty swallowing is at risk for airway complications and requires close observation by a more experienced nurse. Increasing anxiety and diaphoresis in a client with Graves' disease can be an indication of impending thyroid storm, which is an emergency. This is not a situation to be managed by a newly graduated RN. A client who has just arrived on
the unit after a parathyroidectomy requires close observation for hypocalcemia, bleeding, and airway compromise and requires assessment by an experienced nurse.
A client at the medical clinic is being evaluated for hypothyroidism. For which of these symptoms consistent with hypothyroidism does the nurse assess? (Select all that apply)
A. Pulse rate below 60 beats per minute
B. Agitation and inability to sleep
C. Increasing thermostat settings in the home
D. Increase in appetite over the last year
E. Bizarre or manic behavior Answer ✓✓ A. Pulse rate below 60 beats per minute
C. Increasing thermostat settings in the home
The nurse assesses the client with hypothyroidism for bradycardia (heart rate below 60). Blood pressure and heart rate and rhythm must be monitored as well as
correct answers
An older client with an elevated serum calcium level is receiving IV furosemide (Lasix) and an infusion of normal saline at 150 mL/hr. Which nursing action can the RN delegate to unlicensed assistive personnel (UAP)?
A. Ask the client about any numbness or tingling.
B. Check for bone deformities in the client's back.
C. Measure the client's intake and output hourly.
D. Monitor the client for shortness of breath. Answer ✓✓ C. Measure the client's intake and output hourly.
Measuring hourly intake and output is a commonly delegated nursing action that is within the UAP scope of practice. Numbness and tingling is part of the client assessment that needs to be completed by a licensed nurse. Bony deformities can be due to pathologic fractures. Physical assessment is a complex task that cannot be delegated to a UAP. An older client receiving an IV at 150 mL/hr is at risk for congestive heart failure. Careful monitoring for shortness of breath is the responsibility of the RN.
The nurse manager for the medical-surgical unit is making staff assignments. Which client will be most appropriate to assign to a newly graduated RN who has completed a 6-week unit orientation?
A. Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily
B. Client with follicular thyroid cancer who has vocal hoarseness and difficulty swallowing C. Client with Graves' disease who is experiencing increasing anxiety and diaphoresis
D. Client with hyperparathyroidism who has just arrived on the unit after a parathyroidectomy Answer ✓✓ A. Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily
The client with chronic hypothyroidism and dementia is the most stable of the clients described and would be most appropriate to assign to an inexperienced RN.A client with vocal hoarseness and difficulty swallowing is at risk for airway complications and requires close observation by a more experienced nurse. Increasing anxiety and diaphoresis in a client with Graves' disease can be an indication of impending thyroid storm, which is an emergency. This is not a situation to be managed by a newly graduated RN. A client who has just arrived on
the unit after a parathyroidectomy requires close observation for hypocalcemia, bleeding, and airway compromise and requires assessment by an experienced nurse.
A client at the medical clinic is being evaluated for hypothyroidism. For which of these symptoms consistent with hypothyroidism does the nurse assess? (Select all that apply)
A. Pulse rate below 60 beats per minute
B. Agitation and inability to sleep
C. Increasing thermostat settings in the home
D. Increase in appetite over the last year
E. Bizarre or manic behavior Answer ✓✓ A. Pulse rate below 60 beats per minute
C. Increasing thermostat settings in the home
The nurse assesses the client with hypothyroidism for bradycardia (heart rate below 60). Blood pressure and heart rate and rhythm must be monitored as well as
