A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia. Which priority intervention should the nurse include in this client's plan of care?
a. Monitor the client's intravenous site every shift.
b. Administer acetaminophen (Tylenol) for fever.
c. Ensure that working suction equipment is in the room.
d. Assess the client's vital signs every 4 hours.
ANS: C
A client with hypothyroidism who develops another illness is at risk for myxedema coma. In this emergency situation, maintaining an airway is a priority. The nurse should ensure that suction equipment is available in the client's room because it may be needed if myxedema coma develops. The other interventions are necessary for any client with pneumonia, but having suction available is a safety feature for this client.
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