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A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
- A. Exophthalmos
- B. Photophobia
- C. Lethargy
- D. Weight loss
Correct Answer: C
Rationale: Rationale: Hypothyroidism is characterized by decreased thyroid hormone levels, leading to symptoms such as lethargy due to slowed metabolism. Exophthalmos (bulging eyes) is associated with hyperthyroidism. Photophobia (sensitivity to light) is not a common symptom of hypothyroidism. Weight loss is more indicative of hyperthyroidism due to increased metabolism. Therefore, the correct answer is C: Lethargy, as it aligns with the expected findings in hypothyroidism.
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A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
- A. Promote oral hygiene.
- B. Ensure adequate nutrition.
- C. Prevent aspiration.
- D. Relieve the client’s pain.
Correct Answer: C
Rationale: The correct answer is C: Prevent aspiration. This is the priority because with intermaxillary fixation, the client's ability to swallow and protect their airway is compromised. Aspiration can lead to serious complications such as pneumonia. Promoting oral hygiene (A) can be important but not the priority. Ensuring adequate nutrition (B) is important but can be addressed once the risk of aspiration has been minimized. Relieving pain (D) is also important but not the priority over preventing aspiration in this case.
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
- A. Induce sedation.
- B. Suppress respiratory effort.
- C. Decrease chest wall compliance.
- D. Decrease respiratory secretions.
Correct Answer: B
Rationale: The correct answer is B: Suppress respiratory effort. Pancuronium is a neuromuscular blocking agent that paralyzes skeletal muscles, including the muscles involved in breathing. In ARDS, the client may have difficulty breathing due to lung damage, so pancuronium can be used to facilitate mechanical ventilation by preventing respiratory muscle movement. This allows the ventilator to control the client's breathing without interference. The other choices are incorrect because pancuronium does not induce sedation (A), affect chest wall compliance (C), or decrease respiratory secretions (D). It solely works to suppress respiratory effort by blocking neuromuscular transmission.
A nurse is preparing to administer 40 mg of furosemide IV. Available is furosemide 10 mg/mL. How many mL should the nurse administer per dose?
Correct Answer: 4
Rationale: Correct Answer: A nurse should administer 4 mL of furosemide per dose. To calculate this, divide the total dose (40 mg) by the concentration (10 mg/mL). 40 mg ÷ 10 mg/mL = 4 mL. This ensures the correct dosage is administered.
Choice B: Incorrect. This choice does not follow the correct calculation method and does not provide the accurate dosage.
Choice C: Incorrect. This choice does not consider the concentration of the medication and does not provide the correct amount to administer.
Choice D: Incorrect. This choice does not involve the necessary division of the total dose by the concentration, resulting in an incorrect answer.
Choice E: Incorrect. This choice does not show a clear calculation method or consideration of the medication concentration.
Choice F: Incorrect. This choice lacks any calculation or explanation, making it an insufficient answer.
Choice G: Incorrect. This choice does not provide any reasoning or calculation to support the amount to administer, making it an inadequate
A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion?
- A. This stage is when testing occurs to identify boundaries of interpersonal behaviors.
- B. Consensus evolves in this stage.
- C. This stage involves constructive efforts on the part of the group members.
- D. Resistance is evident as subgroups form in this stage.
Correct Answer: B
Rationale: The correct answer is B: Consensus evolves in this stage. During the norming stage of group development, members begin to resolve conflicts and establish norms and values. Consensus-building is crucial in this stage to ensure everyone is on the same page and working towards common goals. This process helps the group to develop cohesion and unity.
Choice A is incorrect because testing occurs in the forming stage, not norming. Choice C is incorrect because constructive efforts typically occur in the performing stage, not norming. Choice D is incorrect because resistance and subgroup formation usually happen in the storming stage, not norming.
A nurse is preparing to administer 0.9% sodium chloride IV infusion 1-L bag at a rate of 200 mL/hr for a client who has rhabdomyolysis. The nurse should expect the IV pump to infuse over how many hours? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 5
Rationale: To calculate the infusion time, divide the total volume (1000 mL) by the rate of infusion (200 mL/hr). This gives 5 hours for the IV pump to infuse the 1-L bag. The correct answer is 5. Other choices are incorrect because they do not result from the correct calculation. Choice A: 2 hours (incorrect, not enough time for the infusion). Choice B: 3 hours (incorrect, not enough time for the infusion). Choice C: 4 hours (incorrect, not enough time for the infusion). Choice D: 6 hours (incorrect, too long for the infusion). Choice E: 7 hours (incorrect, too long for the infusion). Choice F: 8 hours (incorrect, too long for the infusion). Choice G: 9 hours (incorrect, too long for the infusion).