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A nurse is reinforcing teaching with a client who has a new diagnosis of hypothyroidism. Which of the following findings should the nurse expect?
- A. Fatigue
- B. Weight loss
- C. Tachycardia
- D. Heat intolerance
Correct Answer: A
Rationale: Fatigue is a common symptom of hypothyroidism due to a slowed metabolism from decreased thyroid hormone production.
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A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?
- A. Reduced fat in the stools
- B. Decreased sodium excretion
- C. Improved respiratory function
- D. Improved absorption of vitamins B and C
Correct Answer: A
Rationale: Reduced fat in the stools is correct. Pancrelipase is an enzyme replacement therapy that helps improve digestion and absorption of fats and proteins in individuals with cystic fibrosis. This treatment is especially important for those with pancreatic insufficiency, as it helps prevent the steatorrhea (fatty stools) commonly seen in these patients.
A nurse is reinforcing teaching with a client who is scheduled for an exercise stress test. Which of the following instructions should the nurse include?
- A. Eat a large meal before the test.
- B. Wear comfortable shoes.
- C. Take a sedative before the test.
- D. Avoid drinking water during the test.
Correct Answer: B
Rationale: Wearing comfortable shoes ensures safety and ease during the physical activity required for an exercise stress test.
A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Tell the staff members to stop their discussion.
- C. Participate in an in-service about client confidentiality.
- D. Speak to the staff members in private about client confidentiality.
Correct Answer: B
Rationale: Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client's medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client's privacy is respected.
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
- A. Anaphylactic
- B. Acute hemolytic
- C. Febrile
- D. Circulatory overload
Correct Answer: A
Rationale: An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.
A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7-month-old infant who is febrile. Available is ibuprofen 50 mg/1.25 mL. How many should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 1.0 mL
- B. 1.2 mL
- C. 1.5 mL
- D. 2.0 mL
Correct Answer: C
Rationale: The correct dose is 1.5 mL. To calculate: (60 mg / 50 mg) * 1.25 mL = 1.5 mL. This ensures the infant receives the prescribed 60 mg of ibuprofen.