Which of the following is the most critical intervention needed for a client with myxedema coma?

Correct Answer: A

Rationale: The correct answer is A: Administering an oral dose of levothyroxine (Synthroid). In myxedema coma, there is severe hypothyroidism leading to altered mental status, hypothermia, and organ failure. Administering levothyroxine is crucial to replace the deficient thyroid hormone rapidly and restore metabolic function. Warming the client (B) is important but secondary to addressing the underlying hormonal imbalance. Measuring intake and output (C) is essential for overall assessment but not the most critical intervention. Maintaining a patent airway (D) is always important in any medical emergency but does not directly address the primary issue of hypothyroidism in myxedema coma.

Correct Answer: D

Rationale: The correct answer is D: The client is experiencing a mild overdosage. Tinnitus is a common symptom of aspirin toxicity. Aspirin overdose can lead to tinnitus due to its ototoxic effects. This occurrence indicates that the client may be taking too much aspirin, resulting in toxicity. The other choices (A, B, C) are incorrect because tinnitus is not a normal side effect of aspirin working correctly, upper GI bleed, or a metallic taste in the mouth.

Correct Answer: B

Rationale: The correct answer is B: Fluorouracil (5-fluorouracil, 5-FU). Fluorouracil is a commonly used chemotherapy drug for treating advanced liver cancer. It works by inhibiting the growth of cancer cells. This drug is specifically effective in targeting rapidly dividing cells, which is a characteristic of cancer cells. Fluorouracil is often used in combination with other chemotherapy drugs to improve treatment outcomes. Summary of other choices: A: Fluoxymesterone (Halotestin) - This is an androgen hormone used to treat certain types of breast cancer, not liver cancer. C: Tamoxifen (Nolvadex) - This is a hormonal therapy drug used in breast cancer, not liver cancer. D: Megestrol (Megace) - This is a hormonal therapy drug used for certain types of cancers, but not typically for liver cancer.

Correct Answer: C

Rationale: Step-by-step rationale: 1. INH (Isoniazid) can lead to peripheral neuropathy due to vitamin B6 deficiency. 2. Pyridoxine is vitamin B6, which helps prevent neuropathy. 3. Supplementing with pyridoxine can counteract the deficiency caused by INH. 4. Thus, option C, supplementing the diet with pyridoxine, is the correct choice. Summary: - Option A is incorrect as a low cholesterol diet does not address the vitamin B6 deficiency. - Option B is incorrect as excessive bed rest does not prevent neuropathy. - Option D is incorrect as sun exposure is not related to the prevention of peripheral neuropathy.

Correct Answer: A

Rationale: The correct answer is A because hanging the chest drainage system on the top of the wheelchair backrest ensures that the system remains upright and secured during transportation, reducing the risk of accidental disconnection or leakage. Placing it on the patient's feet (B), hanging it with the IV pole (C), or placing it in the patient's lap (D) can lead to potential complications such as pulling or kinking the drainage tubing, increasing the risk of infection or injury to the patient.

Correct Answer: B

Rationale: The correct answer is B: Phenytoin (Dilantin). Phenytoin is known to cause gingival hyperplasia as a side effect, which can be minimized with good oral hygiene practices. Procainamide, Azathioprine, and Allopurinol are not associated with gingival hyperplasia. Therefore, the client receiving cyclosporine should focus on practicing good oral hygiene specifically when taking Phenytoin to minimize the risk of developing gingival hyperplasia.

Correct Answer: D

Rationale: The correct answer is D: Draw up clear insulin first when mixing two types of insulin in one syringe. This is important because mixing insulin requires drawing up the clear (short-acting) insulin first to prevent contamination. This ensures accurate dosing and prevents clouding of the insulin. Drawing up cloudy insulin first can lead to inaccurate dosing and potential mixing errors. Administering insulin after the first meal (choice A) is not the focus of this question. Administering insulin at a 45-degree angle into the deltoid muscle (choice B) is not recommended for insulin injections. Vigorously shaking the vial of insulin before withdrawal (choice C) can cause bubbles and affect the accuracy of the dose.

Correct Answer: B

Rationale: The correct answer is B: IV drugs and chemicals. Thrombophlebitis is inflammation of a vein with blood clot formation, commonly caused by irritants like IV drugs. Impaired mobility (C) and compromised circulation (D) are risk factors for thrombophlebitis, but not specific to older adults with heart and blood vessel diseases. A is incorrect as not all choices apply in this scenario.

Correct Answer: A

Rationale: The correct answer is A because evaluating a nursing intervention involves collecting data to determine if the goals set for the intervention were achieved. This process helps in assessing the effectiveness of the intervention in meeting the desired outcomes. Option B is incorrect as it refers to the identification of nursing diagnoses for new problems, which is part of the nursing assessment phase, not evaluation. Option C is incorrect as adjusting the care plan to include collaborative interventions is part of the implementation phase, not evaluation. Option D is incorrect as performing client care tasks as per protocol is part of the implementation phase, not evaluation.