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A nurse is collecting data from a client who has hyperthyroidism and is taking propylthiouracil. Which of the following statements by the client indicates the medication is effective?
- A. I continue to lose weight.
- B. I have less oily skin.
- C. I no longer feel nervous.
- D. I no longer take a stool softener.
- E. I feel more tired.
- F. My appetite has decreased.
- G. My heart rate is faster.
Correct Answer: C
Rationale: Reduced nervousness indicates propylthiouracil is controlling hyperthyroid symptoms like anxiety.
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A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?
- A. Nerve damage
- B. Infection
- C. Infiltration
- D. Phlebitis
Correct Answer: C
Rationale: Edema, coolness, and tenderness suggest infiltration, where IV fluid leaks into surrounding tissue. Infection involves warmth/redness, phlebitis includes inflammation, and nerve damage affects sensation/movement.
A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?
- A. You will not become fatigued when you use assistive devices.
- B. Plan to hire a home care aid to perform all of your ADLs.
- C. Install grab bars in your shower to assist with your balance.
- D. Place a towel in the shower to prevent slipping.
Correct Answer: C
Rationale: Grab bars support balance and safety, key for CVA clients with ADL challenges. Other options are impractical or unsafe.
A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed for 1 hr after the feeding
- B. Administer the feeding solution at a cold temperature.
- C. Rotate the jejunostomy tube once per day.
- D. Flush the tube with 90 mL of sterile water before and after the feeding
Correct Answer: A
Rationale: Elevating the head for 1 hour prevents aspiration, essential for jejunostomy feeding safety. Cold solutions, rotation, and large flushes are not recommended.
A nurse is collecting data from a client who is perimenopausal. Which of the following findings is the priority for the nurse to report to the provider?
- A. Difficulty sleeping
- B. Hot flashes
- C. Vaginal dryness
- D. Urinary frequency
Correct Answer: D
Rationale: Perimenopause involves hormonal shifts causing various symptoms, but priority follows clinical urgency. Urinary frequency stands out it could indicate a urinary tract infection, bladder dysfunction, or even a gynecologic issue like prolapse, all requiring prompt evaluation. Difficulty sleeping, hot flashes, and vaginal dryness are classic perimenopausal symptoms from estrogen decline, managed symptomatically unless severe. Frequency, however, suggests a potential complication beyond hormonal changes, possibly impacting renal or pelvic health. Using the ABCs or Maslow's hierarchy, urinary issues tie to elimination needs, outranking sleep or comfort concerns. Reporting this ensures timely diagnosis (e.g., urinalysis) and treatment, preventing progression to pyelonephritis or chronic conditions, making it the most pressing finding to escalate.
A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the client's blood with a solution of water and which of the following cleaning agents?
- A. Isopropyl alcohol
- B. Hydrogen peroxide
- C. Bleach
- D. Chlorhexidine
Correct Answer: C
Rationale: AIDS, caused by HIV, requires strict infection control due to bloodborne transmission risk. Option C, bleach (typically a 1:10 dilution with water), is correct CDC guidelines recommend it for disinfecting HIV-contaminated surfaces, as it effectively inactivates the virus by denaturing proteins. Option A, isopropyl alcohol, disinfects but isn't the standard for blood spills; it evaporates quickly, potentially leaving viable pathogens. Option B, hydrogen peroxide, oxidizes but lacks evidence as a primary bloodborne pathogen disinfectant compared to bleach. Option D, chlorhexidine, excels for skin antisepsis, not environmental surfaces or blood cleanup. Bleach's broad-spectrum efficacy, affordability, and alignment with universal precautions make it the gold standard. Teaching this ensures the new nurse protects themselves and others, adhering to OSHA and hospital protocols, while reinforcing the importance of proper dilution (e.g., 1 part bleach to 9 parts water) for safety and effectiveness.