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A client with a diagnosis of hyperthyroidism is prescribed methimazole (Tapazole). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Agranulocytosis.
- C. Hypertension.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Methimazole can cause agranulocytosis, requiring monitoring of white blood cell counts.
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The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for? Select all that apply.
- A. Sepsis.
- B. Hypovolemia.
- C. Hyperkalemia.
- D. Respiratory distress.
- E. Hypoglycemia.
Correct Answer: A, B, C, D
Rationale: Burns can cause sepsis (infection), hypovolemia (fluid loss), hyperkalemia (tissue damage), and respiratory distress (inhalation injury).
The nurse is caring for a client who has just undergone a tonsillectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage frequent swallowing.
- B. Monitor for excessive swallowing.
- C. Offer ice chips immediately.
- D. Keep the head of the bed flat.
Correct Answer: B
Rationale: Monitoring for excessive swallowing is critical post-tonsillectomy, as it may indicate bleeding from the surgical site.
What are the nursing implications associated with administering blood and blood products to a client who has a blood type of B negative?
- A. The nurse must be knowledgeable about the fact that this client has A and B agglutinins and lacks the Rh factor
- B. The nurse must be knowledgeable about the fact that this client has B and O agglutinins and lacks the Rh factor
- C. The nurse must be knowledgeable about the fact that this client has B agglutinins and lacks the Rh factor
- D. The nurse must be knowledgeable about the fact that this client has A agglutinins and lacks the Rh factor
Correct Answer: C
Rationale: B negative blood type has anti-A agglutinins (antibodies against A antigen) and lacks the Rh factor, requiring careful matching to avoid transfusion reactions.
Which of the following should the nurse teach a client with generalized anxiety disorder to help the client cope with anxiety?
- A. Cognitive and behavioral strategies.
- B. Issue avoidance and denial of problems.
- C. Rest and sleep.
- D. Withdrawal from role expectations and role relationships.
Correct Answer: A
Rationale: Cognitive and behavioral strategies, such as relaxation techniques, help clients manage anxiety effectively.
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart below. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart below. What should the nurse do next?
- A. Notify the neonatologist on call.
- B. Continue to assess the neonate.
- C. Apply an oxygen mask.
- D. Rub the neonate's extremities.
Correct Answer: B
Rationale: Without specific Apgar score data, the standard action is to continue assessing the neonate, as Apgar scores at 5 minutes guide ongoing monitoring unless critical findings are present.