Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which intervention should the nurse delegate to the UAP?
- A. Assist the client with abdominal pain to turn to the side and flex the knees.
- B. Monitor the Jackson Pratt drainage tube to ensure it is draining properly.
- C. Check to see if the client is sleeping after pain medication is administered.
- D. Empty the bedside commode of the client who has been having melena.
Correct Answer: A
Rationale: Assisting with positioning is within the UAP’s scope and promotes comfort. Monitoring drains, assessing sleep, and handling melena require RN skills.
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The agitated client is hospitalized with tachycardia, dyspnea, and intermittent chest palpitations. The client's BP is 170/110 mm Hg, and HR is 130 bpm. The client's health history reveals thinning hair, recent 10-lb weight loss, increased appetite, fine hand and tongue tremors, hyperreflexic tendon reflexes, and smooth, moist skin. Which prescribed intervention should be the nurse's priority?
- A. 12-lead electrocardiogram (ECG) and cardiac enzyme levels.
- B. Obtain thyroid-stimulating hormone (TSH) and free T4 levels.
- C. Propranolol 2 mg IV q15 min or until symptoms are controlled.
- D. Propylthiouracil 600-mg oral loading dose; then 200 mg orally q4h.
Correct Answer: C
Rationale: Propranolol provides rapid symptomatic relief of thyrotoxicosis by controlling cardiac and psychomotor manifestations.
The client is ready for discharge following an adrenalectomy. Which statement that the client makes indicates the best understanding of the client's condition?
- A. I will continue on a low-sodium, low-potassium diet.'
- B. My husband has arranged for a marriage counselor because of our fights.'
- C. I will stay out of the sun so I will not turn splotchy brown.'
- D. I will take all of those pills every day.'
Correct Answer: D
Rationale: Lifelong steroid replacement is required post-adrenalectomy, and taking prescribed pills daily shows understanding. A high-sodium, low-potassium diet is needed, and photosensitivity is not an issue.
The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective?
- A. The client has a three (3)-pound weight gain.
- B. The client has a decreased pulse rate.
- C. The client's temperature is WNL.
- D. The client denies any diaphoresis.
Correct Answer: C
Rationale: Normal temperature indicates corrected hypothermia from hypothyroidism. Weight gain, decreased pulse, and no diaphoresis are not specific indicators.
The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has developed an infection in the adrenal gland. Which client problem is highest priority?
- A. Altered body image.
- B. Activity intolerance.
- C. Impaired coping.
- D. Fluid volume deficit.
Correct Answer: D
Rationale: Adrenal infection may impair aldosterone production, causing fluid volume deficit (hypovolemia), a priority. Body image, activity, and coping are psychosocial and secondary.
The client taking NPH insulin at 0800 reports feeling anxious and shaky in the midafternoon. Which intervention is best for the nurse to initiate?
- A. Have the client rate the level of anxiety.
- B. Give the client's prn dose of lorazepam.
- C. Check the client's fingerstick blood glucose level.
- D. Advise the client to sit in a recliner to relax.
Correct Answer: C
Rationale: The best intervention is to check a fingerstick blood glucose level because anxiety and shakiness in the midafternoon when taking NPH insulin could indicate hypoglycemia; NPH insulin peaks in 6-8 hours after administration.