Nokea
The nurse is caring for a client with a history of hyperthyroidism.
- A. Which assessment finding is expected in a client with untreated hyperthyroidism?
- B. Bradycardia and weight gain.
- C. Tremors and heat intolerance.
- D. Fatigue and cold intolerance.
- E. Constipation and dry skin.
Correct Answer: B
Rationale: Tremors and heat intolerance are classic symptoms of hyperthyroidism due to increased metabolism. Bradycardia, weight gain, fatigue, and constipation are associated with hypothyroidism.
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The nurse is caring for a client with a history of deep vein thrombosis.
- A. Which intervention is most important for a client with a deep vein thrombosis?
- B. Administer analgesics for pain relief.
- C. Apply warm, moist compresses to the leg.
- D. Encourage active range-of-motion exercises.
- E. Maintain bed rest with leg elevation.
Correct Answer: D
Rationale: Bed rest with leg elevation reduces venous pressure and prevents clot dislodgement in DVT. Analgesics and compresses are supportive, and active exercises risk embolization.
A client is given morphine 6 mg IV push for postoperative pain.
- A. What is the most appropriate nursing action for a client with pulse 68, respirations 8, BP 100/68, and sleeping quietly after receiving morphine 6 mg IV?
- B. Allow the client to sleep undisturbed.
- C. Administer oxygen via facemask or nasal prongs.
- D. Administer naloxone (Narcan).
- E. Place epinephrine 1:1,000 at the bedside.
Correct Answer: C
Rationale: A respiratory rate of 8 indicates respiratory depression, a serious side effect of morphine. Administering naloxone (Narcan) is the most appropriate action to reverse this effect. Allowing the client to sleep risks further respiratory compromise, oxygen may be used after naloxone, and epinephrine is not indicated.
A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
- A. I cannot give this medication as it is written. I have no idea of what you mean.
- B. Would you please clarify what you have written so I am sure I am reading it correctly?
- C. I am having difficulty reading your handwriting. It would save me time if you would be more careful.
- D. Please print in the future so I do not have to spend extra time attempting to read your writing.
Correct Answer: B
Rationale: Would you please clarify what you have written so I am sure I am reading it correctly? This is respectful and ensures patient safety.
A client after right cataract surgery.
The nurse would intervene in which of the following situations?
- A. Client is in the supine position.
- B. The head of the bed is elevated 30°.
- C. The client is lying on her right side.
- D. An eye shield is over the right eye.
Correct Answer: C
Rationale: Strategy: 'Nurse would intervene' indicates an incorrect action. (1) appropriate position (2) decreases swelling and pain (3) correct-client should not be positioned with operative side in a dependent position or against the bed (4) shield is appropriate
A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?
- A. Double vision and visual halos
- B. Extremity tingling and numbness
- C. Confusion and lightheadedness
- D. Sensitivity of sunlight
Correct Answer: B
Rationale: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be reported to the provider. It can be reversed.