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A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Bradycardia and constipation.
- B. Lethargy and lack of appetite.
- C. Muscle cramping and dry, flushed skin.
- D. Palpitations and shortness of breath.
Correct Answer: D
Rationale: Palpitations and shortness of breath indicate hyperthyroidism from excessive levothyroxine, requiring dosage adjustment.
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The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
- A. Administer IV fluid bolus as prescribed by the healthcare provider.
- B. Encourage the client to splint the Incision with a pillow to cough and deep breathe.
- C. Medicate for pain and monitor vital signs according to protocol.
- D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.
Correct Answer: C
Rationale: Pain medication addresses tachycardia and tachypnea likely caused by postoperative pain, stabilizing vital signs.
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
- A. Educate client on signs and symptoms of narcotic dependency.
- B. Administer opioid and non-opioid medication simultaneously.
- C. Give maximum dosage when score reaches 10.
- D. Alternate IV and IM analgesic medications.
Correct Answer: B
Rationale: Combining opioid and non-opioid medications provides synergistic pain relief, optimizing control while minimizing opioid side effects.
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Increase Intake of potassium rich foods such as bananas or cantaloupe.
- B. Restrict protein intake by limiting meats and other high protein foods.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of high fiber foods, such as bran cereal.
Correct Answer: B
Rationale: Restricting protein reduces kidney workload and proteinuria, preserving function in glomerulonephritis.
The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?
- A. Verify prescribed laboratory tests include prothrombin time and platelet count.
- B. Administer aspirin to prevent further clot formation and platelet clumping.
- C. Maintain elevated positioning of the dependent joints on affected side.
- D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
Correct Answer: D
Rationale: IV catheters and fibrinolytic criteria review are critical for potential thrombolytic therapy in suspected ischemic stroke.
History and Physical Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.
- A. Blood pressure 130/86 mmHg
- B. Respirations 28 breaths/minute
- C. Temperature 98.9" F (37.1°C)
- D. Heart rate 112 beats/minute
- E. Oxygen saturation 88% on room air
Correct Answer: A,B
Rationale: Tachypnea results from bronchospasm in asthma, impairing ventilation. Elevated heart rate is a side effect of beta-agonist inhalers used during the attack.