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To assess pedal pulses, which arterial sites should the nurse palpate? (Select all that apply)
- A. Posterior tibial artery
- B. Radial artery
- C. External iliac artery
- D. Dorsalis pedis artery
Correct Answer: D
Rationale: The correct answer is D: Dorsalis pedis artery. When assessing pedal pulses, the nurse should palpate the dorsalis pedis artery and the posterior tibial artery. The radial artery is located in the wrist and is not a site for assessing pedal pulses. The external iliac artery is not a correct site for assessing pedal pulses in the lower extremities, making it the correct answer.
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Which nonfood item is the most common cause of respiratory arrest in young children?
- A. Broken rattles
- B. Buttons
- C. Pacifiers
- D. Latex balloons
Correct Answer: D
Rationale: The correct answer is D, Latex balloons. Latex balloons can pose a significant choking hazard to young children if inhaled, potentially leading to respiratory arrest. Broken rattles, buttons, and pacifiers are not typically known to cause respiratory arrest in young children. While these items can present choking hazards as well, the most common cause of respiratory arrest among young children is due to inhaling latex balloons.
An adult female client is admitted to the psychiatric unit with a diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement?
- A. Tell the client to keep her belongings because she will need them at discharge
- B. Ask the client if she has had any recent thoughts of harming herself
- C. Reassure the client that the antidepressant drugs are apparently effective
- D. Support the client by telling her what wonderful progress she is making
Correct Answer: B
Rationale: In this scenario, the nurse should ask the client if she has had any recent thoughts of harming herself. Sudden mood improvements and behavioral changes, like giving away belongings, can be concerning signs of possible suicidal ideation. Assessing for suicidal thoughts is crucial to ensure the client's safety. Choice A is incorrect as it does not address the potential risk of harm or assess for suicidal ideation. Choice C is incorrect because simply reassuring the client about the effectiveness of antidepressants does not address the immediate concern of suicidal ideation. Choice D is incorrect as it focuses on praising progress without addressing the potential risk of harm the client may pose to herself.
A client with hypothyroidism is being treated with levothyroxine (Synthroid). What is the most important information for the nurse to provide to the client?
- A. Take the medication on an empty stomach
- B. Monitor for signs of hyperthyroidism
- C. Expect to see results within a week
- D. Avoid exposure to sunlight
Correct Answer: B
Rationale: The most important information for the nurse to provide to a client with hypothyroidism being treated with levothyroxine is to monitor for signs of hyperthyroidism. Too much levothyroxine can lead to symptoms of hyperthyroidism, indicating an overdose. Choice A is incorrect as levothyroxine is usually taken on an empty stomach to ensure optimal absorption. Choice C is inaccurate as it may take weeks to months to see the full effects of levothyroxine therapy due to the need for dosage adjustments. Choice D is unrelated to levothyroxine therapy and is not a crucial concern for this specific medication.
The nurse is assessing a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?
- A. Slow the rate of transfusion.
- B. Administer an antipyretic.
- C. Stop the transfusion immediately.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: The correct answer is C: Stop the transfusion immediately. Chills and back pain are indicative of a possible transfusion reaction, which is a critical situation. Stopping the transfusion is crucial to prevent further complications and ensure the client's safety. Slowing the rate of transfusion (Choice A) is not sufficient in this case as immediate action is required. Administering an antipyretic (Choice B) may help with fever but does not address the potential severe reaction. Notifying the healthcare provider (Choice D) can be done after stopping the transfusion, but the priority is to halt the infusion to prevent harm.
A client with a diagnosis of rheumatoid arthritis is prescribed methotrexate. What is the primary action of this medication?
- A. Increases joint lubrication
- B. Reduces inflammation by suppressing the immune system
- C. Enhances bone density
- D. Stimulates cartilage regeneration
Correct Answer: B
Rationale: The correct answer is B: Methotrexate is an immunosuppressant that works by suppressing the immune system, thereby reducing inflammation in rheumatoid arthritis. Methotrexate does not directly increase joint lubrication (Choice A) as its primary action is on the immune system. Choices C and D are incorrect since methotrexate does not enhance bone density or stimulate cartilage regeneration. It is crucial for healthcare providers to understand the mechanism of action of medications to provide safe and effective care to patients.