The nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?

Correct Answer: D

Rationale: The nurse should observe for muscle twitching and numbness or tingling of the lips, fingers, and toes in a client who had a thyroidectomy and is at risk for hypocalcemia. Hypocalcemia is a potential complication following thyroidectomy because the parathyroid glands may be inadvertently removed or damaged during the surgery, leading to decreased calcium levels in the blood. Symptoms of hypocalcemia include muscle twitching (especially in the face), and numbness or tingling around the lips, fingers, and toes. Prompt recognition of these symptoms is crucial as severe hypocalcemia can lead to more serious complications, such as seizures and laryngospasm. Monitoring for these signs allows the nurse to intervene early and prevent further complications.

Correct Answer: C

Rationale: Washing your feet in hot water is not recommended for diabetic foot care as it can increase the risk of burns and skin damage due to reduced sensitivity and circulation in the feet. Instead, it is advised to wash your feet in warm water, not hot, and to thoroughly dry them, especially in between the toes, to prevent fungal infections.

Correct Answer: C

Rationale: Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure characterized by rapidly progressive dyspnea, hypoxemia, and noncardiogenic pulmonary edema. The key signs of ARDS include severe respiratory distress, low partial pressure of oxygen (paO2), and bilateral infiltrates on chest x-ray. In the given scenario, the client presenting with restlessness and suprasternal retractions along with a paO2 level of 62 indicates severe respiratory distress and hypoxemia, which are consistent with ARDS. Therefore, option C is the most indicative of ARDS among the choices provided.

Correct Answer: B

Rationale: Angina pectoris is chest pain or discomfort caused by a temporary lack of an adequate blood supply to the heart muscle (myocardium). This lack of blood supply results in a decreased supply of oxygen to the heart muscle, leading to chest pain. This condition is commonly associated with coronary artery disease, where the arteries that supply blood to the heart become narrowed or blocked, reducing the flow of oxygen-rich blood to the myocardium. This oxygen deficit can trigger chest pain, which is characteristic of angina pectoris. Therefore, the cause of angina pectoris is the inadequate supply of oxygen to the myocardium, making option B the correct answer.

Correct Answer: B

Rationale: Hyperkalemia is a common complication in patients with chronic renal failure due to the kidneys' inability to excrete potassium efficiently. The correct intervention for hyperkalemia includes assessing the patient for muscle weakness, diarrhea, and ECG changes. Muscle weakness is a common symptom of hyperkalemia due to its effects on neuromuscular function. Diarrhea can lead to potassium loss from the gastrointestinal tract, helping to lower potassium levels. ECG changes are essential to monitor in hyperkalemia as high potassium levels can result in life-threatening cardiac arrhythmias. By identifying these signs and symptoms early, appropriate interventions can be initiated promptly, such as administering medications to lower potassium levels or adjusting the patient's diet to limit potassium intake.