Nokea
The clinic nurse evaluates a client’s response to levothyroxine after 8 weeks of treatment. What therapeutic responses to the medication should the nurse expect? Select all that apply.
- A. Apical heart rate of 88/min
- B. Elevation of mood
- C. Improved energy levels
- D. Skin is cool and dry
- E. Slight weight gain
Correct Answer: A,B,C
Rationale: Levothyroxine corrects hypothyroidism, normalizing heart rate (88/min), improving mood, and increasing energy. Skin should be warm/moist, and weight loss is expected, not gain.
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A 6-month old is brought to the ER by her mother. During the assessment, the nurse finds multiple bruises in different stages of healing and decreased range of motion of the right leg. X-ray confirms a fracture of the right femur. Which statement made by the mother would contribute to a diagnosis of child abuse?
- A. She got her leg caught in the crib and twisted it.
- B. She hurt her leg while she was crawling.
- C. I can't remember her falling or getting hurt.
- D. She fell out of her car seat before I could get the belt fastened.
Correct Answer: C
Rationale: The mother's inability to recall any injury event, combined with multiple bruises and a femur fracture, raises suspicion of child abuse due to inconsistent history.
A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?
- A. Magnesium sulfate 4 gm (25%) IV
- B. Brethine 10 mcg IV
- C. Stadol 1 mg IV push every 4 hours PRN for pain
- D. Ancef 2 gm IVPB every 6 hours
Correct Answer: B
Rationale: Brethine (terbutaline) is a tocolytic used to stop preterm labor, which is inappropriate at 34 weeks with diabetes, as delivery may be indicated. Magnesium sulfate is used for preeclampsia, Stadol is for pain, and Ancef is an antibiotic, all of which may be appropriate.
The nurse is reviewing the chart of a client who gave birth 4 hours ago. Which factor increases the client's risk for postpartum hemorrhage?
- A. Labor and birth without pain medication
- B. Labor length of 8 hours
- C. Newborn weight of 9 lb 2 oz (4140 g)
- D. Third stage of labor lasting 20 minutes
Correct Answer: C
Rationale: A large newborn (macrosomia, >4000 g) increases the risk of uterine atony, a major cause of postpartum hemorrhage. Labor without pain medication, an 8-hour labor, and a 20-minute third stage are not significant risk factors.
The nurse is performing a neurological assessment on a client post right cerebral vascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention?
- A. Decrease in level of consciousness
- B. Loss of bladder control
- C. Altered sensation of stimuli
- D. Emotional lability
Correct Answer: A
Rationale: Decrease in level of consciousness. A further decrease in the level of consciousness would be indicative of a further progression of the CVA.
The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action?
- A. Apply a gauze wrap and elastic stockinette around the IV site
- B. Apply a mitt on the right hand
- C. Apply a soft wrist restraint on the right wrist
- D. Apply an arm board to the left arm
Correct Answer: D
Rationale: An arm board on the left arm stabilizes the IV site, reducing pulling without restraining the client, aligning with least-restrictive interventions. Mitts or restraints on the right side do not protect the left-sided IV.