Nokea
A client with a history of hypothyroidism is prescribed levothyroxine (Synthroid). The nurse should monitor the client for which of the following signs of overdose?
- A. Tachycardia.
- B. Weight gain.
- C. Cold intolerance.
- D. Bradycardia.
Correct Answer: A
Rationale: Tachycardia indicates levothyroxine overdose due to excessive thyroid hormone.
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A client has just been diagnosed with right leg venous thromboembolism (VTE). Which interventions should the nurse implement? Select all that apply.
- A. Ice packs to the right leg
- B. Elevation of the right leg
- C. Hourly calf measurements
- D. Vigorous range of motion to the right leg
- E. Reposition the client carefully at regular intervals
Correct Answer: B,E
Rationale: Treatment for deep vein embolism (DVE) may require bed rest with repositioning of the client carefully at regular intervals, leg elevation, and application of warm moist heat to the affected leg. The client may have calf measurements prescribed once per shift or once per day, but they would not be obtained hourly. Option 1 is incorrect because heat, not cold, may be prescribed. Option 4 is dangerous to the client because vigorous activity after clot formation can cause pulmonary embolus.
A client has been taking benzonatate as prescribed. The nurse should tell the client this medication performs which action?
- A. Increases comfort level
- B. Decreases anxiety level
- C. Calms the persistent cough
- D. Takes away nausea and vomiting
Correct Answer: C
Rationale: Benzonatate is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough, without eliminating the cough reflex. The remaining options are not intended effects of this medication.
When cleaning the skin around an incision and drain site, which of the following procedures should the nurse follow?
- A. Clean the incision and drain site separately.
- B. Clean from the incision to the drain site.
- C. Clean from the drain site to the incision.
- D. Clean the incision and drain site simultaneously.
Correct Answer: A
Rationale: Cleaning separately prevents cross-contamination between the incision and drain site, reducing infection risk.
During a clinic visit for a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best?
- A. The hormonal changes your body is experiencing are causing you to feel this way.'
- B. Most new mothers feel the same way that you do. I hear that a lot from others.'
- C. You need to have your husband and family help you so that you can get some rest.'
- D. I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling.'
Correct Answer: D
Rationale: Acknowledging the mother's feelings and encouraging her to elaborate promotes therapeutic communication and helps assess for postpartum depression or other concerns. Attributing feelings solely to hormones, normalizing without exploration, or suggesting family help without assessment may miss underlying issues.
The mother of the child diagnosed with Kawasaki disease asks the nurse about the disorder. On which description of this disorder should the nurse base the response to the mother?
- A. It is an acquired cell-mediated immunodeficiency disorder.
- B. It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue.
- C. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown etiology.
- D. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.
Correct Answer: C
Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus infection. Option 2 describes systemic lupus erythematosus. Option 4 describes rheumatic fever.