Nokea
The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?
- A. Increased TSH
- B. Increased thyroxine (T4)
- C. Decreased TSH
- D. Decreased T3
Correct Answer: A
Rationale: The correct answer is A: Increased TSH. In hypothyroidism, the thyroid gland is underactive, leading to low levels of thyroid hormones. As a compensatory mechanism, the pituitary gland releases more thyroid-stimulating hormone (TSH) to try to stimulate the thyroid gland to produce more hormones. Therefore, increased TSH levels are expected in hypothyroidism. Choice B is incorrect because in hypothyroidism, thyroxine (T4) levels are usually decreased, not increased. Choice C is incorrect as hypothyroidism is characterized by increased TSH levels, not decreased. Choice D is also incorrect because in hypothyroidism, T3 levels may be decreased, but TSH is a more sensitive indicator for diagnosis.
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A client with multiple sclerosis is experiencing fatigue. What is the nurse's priority intervention?
- A. Encourage the client to increase physical activity.
- B. Encourage the client to take rest breaks during activities.
- C. Administer a stimulant medication to reduce fatigue.
- D. Advise the client to use energy conservation techniques.
Correct Answer: D
Rationale: The correct answer is D: Advise the client to use energy conservation techniques. Energy conservation techniques are crucial in managing fatigue in multiple sclerosis. These techniques involve prioritizing activities, pacing oneself, and taking rest breaks to prevent overexertion, which can exacerbate fatigue. Encouraging the client to increase physical activity (choice A) may worsen fatigue if not done with proper energy conservation. Taking rest breaks during activities (choice B) is important but falls secondary to teaching energy conservation techniques. Administering a stimulant medication to reduce fatigue (choice C) should not be the priority as non-pharmacological interventions like energy conservation should be attempted first.
An unlicensed assistive personnel (UAP) reports a weak pulse of 44 beats per minute in a client. What action should the charge nurse implement?
- A. Have the UAP recheck the pulse and report back.
- B. Have a licensed practical nurse (LPN) assess the client for apical-radial pulse deficit.
- C. Call the healthcare provider for further instructions.
- D. Immediately call the healthcare provider and prepare for transfer to critical care.
Correct Answer: B
Rationale: The correct action is to have a licensed practical nurse (LPN) assess the client for an apical-radial pulse deficit. This assessment can provide further information about the client's cardiovascular status and help determine if further intervention is necessary. Having the UAP recheck the pulse may delay appropriate assessment and intervention. Calling the healthcare provider for further instructions may not be necessary at this point unless the LPN assessment indicates a need for it. Immediately transferring the client to critical care without further assessment is not warranted based solely on the initial report of a weak pulse.
An older client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?
- A. Recent compliance with prescribed medications.
- B. Sleep patterns during the previous few weeks.
- C. History of smoking over the past 6 months.
- D. Activity level prior to the onset of symptoms.
Correct Answer: A
Rationale: The correct answer is A. In this scenario, the most critical information for the nurse to obtain during the initial interview is the recent compliance with prescribed medications. This is crucial to understand the client's baseline condition and management of chronic emphysema. Monitoring medication adherence can provide insights into potential exacerbating factors that may have led to the current acute symptoms. Choices B, C, and D are not as crucial in this situation. Sleep patterns, smoking history, and activity levels are important aspects of the client's overall health but do not take precedence over medication compliance when addressing acute symptoms in a client with chronic emphysema.
A client receiving IV heparin reports abdominal pain and tarry stools. What is the nurse's priority action?
- A. Prepare to administer protamine sulfate.
- B. Continue the heparin infusion and notify the healthcare provider.
- C. Monitor the client's vital signs and assess abdominal pain.
- D. Administer a PRN dose of morphine sulfate.
Correct Answer: A
Rationale: The correct answer is to prepare to administer protamine sulfate. Abdominal pain and tarry stools are indicative of gastrointestinal bleeding, a serious side effect of heparin therapy. Protamine sulfate is the antidote for heparin and is used to reverse its effects in cases of bleeding. Continuing the heparin infusion (Choice B) is not appropriate when the client is experiencing signs of bleeding. Monitoring vital signs and assessing abdominal pain (Choice C) is important but not the priority when immediate action is required to address potential bleeding. Administering morphine sulfate (Choice D) is not the priority in this situation; addressing the underlying cause of bleeding takes precedence.
Which intervention should be prioritized by the nurse when assessing tissue perfusion post-above knee amputation (AKA)?
- A. Evaluate the closest proximal pulse.
- B. Observe color and amount of wound drainage.
- C. Observe for swelling around the stump.
- D. Assess the skin elasticity of the stump.
Correct Answer: A
Rationale: The correct answer is to evaluate the closest proximal pulse when assessing tissue perfusion post-above knee amputation (AKA). Checking the closest proximal pulse provides the best indication of tissue perfusion in the extremities after an AKA procedure. Observing the color and amount of wound drainage (Choice B) is important for wound care but does not directly assess tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or fluid accumulation but is not the most direct way to assess tissue perfusion. Assessing the skin elasticity of the stump (Choice D) is more related to skin integrity and wound healing rather than tissue perfusion.