Nokea
The nurse is caring for an 8-month-old client with suspected acute otitis media. Which of the following findings would be consistent with the condition? Select all that apply.
- A. Frequent pulling on the affected ear
- B. Purulent drainage from the affected ear
- C. Refusal to eat
- D. Restlessness and irritability
- E. Retracted tympanic membranes
Correct Answer: A,C,D
Rationale: Ear pulling, refusal to eat, and irritability are common in otitis media due to pain and inflammation. Purulent drainage is less common unless the eardrum ruptures, and tympanic membranes are typically bulging, not retracted.
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While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first?
- A. First-trimester client who reports frequent nausea and vomiting
- B. Second-trimester client with dysuria and urinary frequency
- C. Second-trimester client with obesity who reports decrease in fetal movement
- D. Third-trimester client with right upper quadrant pain and nausea
Correct Answer: C
Rationale: Decreased fetal movement in the second trimester suggests potential fetal distress, requiring urgent evaluation. Nausea, UTI symptoms, and third-trimester pain are concerning but less immediately critical.
The afternoon following a thyroidectomy, the client experiences all of the following. Which one indicates to the nurse that the client is experiencing a serious complication?
- A. A sore throat
- B. Pain at the surgical site
- C. Temperature of 100.2°F
- D. Sudden hoarseness
Correct Answer: D
Rationale: Sudden hoarseness post-thyroidectomy may indicate vocal cord paralysis or hematoma compressing the airway, a serious complication requiring immediate attention. Sore throat, surgical pain, or mild fever are expected.
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.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client's current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: A major disadvantage of long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant adverse effects, including fatigue, dizziness, and erectile dysfunction. In addition, clients may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. Abrupt discontinuation of prescribed antihypertensive medications can lead to hypertensive crisis, a life-threatening emergency characterized by severely elevated blood pressure (ie, systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). To prevent complications (eg, end organ damage), the nurse should determine if the client has been taking the medications consistently (Option 4). There may be a need for a dosage change or addition of another medication.
Home Medications
Vital signs
Temperature 98.5 F (36.9 C)
Blood pressure 110/74 mm Hg
Heart rate 68/min
Respirations 16/min
SpO2 97% on room air
Medication Prescription
Medication prescription
Clopidogrel: 75 mg PO, daily
Metoprolol XL: 50 mg PO, daily
Furosemide: 40 mg PO, twice daily
Fish oil: 4 g PO, daily
Intake and Output Record
Intake and output record
Time Oral Intake Output
0700 200 mL
0800 125 mL
1000 100 mL 250 mL
1200 200 mL 250 mL
1500 150 mL 375 mL
The nurse is caring for a client with coronary artery disease and heart failure. Which of the following findings would require immediate follow-up?
- A. bruises easily on the arms
- B. reports chronic fatigue
- C. muscle cramps in the legs
- D. reports feeling depressed
Correct Answer: C
Rationale: Hypokalemia (serum potassium <3.5 mEq/L [<3.5 mmol/L]) is a common adverse effect of potassium-wasting diuretics (eg,furosemide) that may cause leg cramps, muscle weakness, or ECG changes. Unmanaged hypokalemia can lead to lethal cardiac dyshythmias (eg, ventricular fibrillation, torsades de pointes) and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia