Nokea
Ken Thom needs instruction on the medications he is taking for his hypothyroidism. You would include which of the following in a teaching plan?
- A. Take medications with meals or with food.
- B. Take medications in the evening or at bedtime.
- C. Report excess weight loss and leg cramps.
- D. Increase the use of iodized salt and spinach.
Correct Answer: C
Rationale: Thyroid medications will be absorbed better if taken on an empty stomach. Thyroid medications would best be taken in the morning, as they may cause difficulty in sleeping when taken at night. Weight loss should occur, but the patient should be taught to report an excessive loss. Leg cramps may indicate a calcium disturbance that needs correction. Iodine is an antithyroid, decreasing thyroid function. Increasing intake of thyroid would effectively act as an antidote to the thyroid medications Mr. Thom is taking.
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Steps to prevent a pressure ulcer may include
- A. Not disturbing the patient.
- B. Changing the position of a bedbound patient every 4 hours.
- C. Vigorously rubbing the skin with alcohol.
- D. Avoiding pressure on the heels of a bedbound patient.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A terminally ill man tells the nurse, “I have never believed there is a God or an afterlife, but now it is too terrible to imagine that I will not exist. Why was I here in the first place?” What does this comment help the nurse recognize about the patient’s needs?
- A. He is experiencing spiritual distress.
- B. This man most likely will not have a peaceful death.
- C. He needs to be reassured that his feelings are normal.
- D. This patient should be referred to a clergyman for a discussion of his beliefs.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nursing student is providing tracheostomy care. What action by the student requires intervention by the instructor?
- A. Holding the device securely when changing ties
- B. Suctioning the client first if secretions are present
- C. Tying a square knot at the back of the neck
- D. Using half-strength peroxide for cleansing
Correct Answer: C
Rationale: The correct answer is C: Tying a square knot at the back of the neck. The reason this action requires intervention is that a square knot is not recommended for securing tracheostomy ties as it can be difficult to untie in an emergency. Instead, a quick-release knot or Velcro closure is typically used for easy removal.
A: Holding the device securely when changing ties is important for maintaining the integrity of the tracheostomy.
B: Suctioning the client first if secretions are present is a standard practice to ensure clear airways.
D: Using half-strength peroxide for cleansing is appropriate for tracheostomy care to prevent infection.
In summary, the incorrect choice is C because tying a square knot can pose risks in an emergency situation, while the other choices are appropriate actions in tracheostomy care.
The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:
- A. infected.
- B. not healing.
- C. necrotic.
- D. healing.
Correct Answer: D
Rationale: The wound is not infected. An infected wound would contain pus, debris, and exudate. A necrotic wound would appear black or brown. The wound is healing properly. It is filled with red granulated tissue and fragile capillaries. A necrotic wound would appear black or brown. The wound is healing properly. It is filled with red granulated tissue and fragile capillaries.
The client's potassium level is 6.7 mEq/L. Which intervention should you delegate to the student nurse under your supervision?
- A. Administer Kayexalate 15 g orally
- B. Administer spironolactone 25 mg orally
- C. Assess ECG strip for tall T waves
- D. Administer potassium 10 mEq orally
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.