Nokea
The nurse is initiating a prescription for levothyroxine for a client with hypothyroidism. Which of the following actions would be most important for the nurse to take?
- A. Ask the client when the last menstrual cycle occurred
- B. Confirm the client’s pregnancy test result is negative
- C. Obtain a baseline assessment of the client’s mouth and throat
- D. Teach the client the signs and symptoms of hypothyroidism
Correct Answer: B
Rationale: Levothyroxine is contraindicated in pregnancy without careful monitoring due to fetal risks, so confirming a negative pregnancy test is critical. Menstrual history is less urgent, mouth/throat assessment is unrelated, and teaching symptoms is important but secondary.
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The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?
- A. Pack the nose and ears with sterile gauze
- B. Apply pressure to the injury site
- C. Apply bulky, loose dressing to nose and ears
- D. Apply an ice pack to the back of the neck
Correct Answer: C
Rationale: Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for the amount of drainage.
A couple from the Philippines living in the United States is expecting their first child. In providing culturally competent care, the nurse must first:
- A. review their own cultural beliefs and biases.
- B. respectfully request that the couple utilize only medically approved health care providers.
- C. realize that the clients have to learn their new country's accepted medical practices.
- D. study family dynamics to understand the male and female gender roles in the clients' culture.
Correct Answer: A
Rationale: Self-awareness of the nurse's own cultural biases is the first step in providing culturally competent care, ensuring nonjudgmental interactions. The other actions are secondary or prescriptive. Psychosocial Integrity
A client’s partner asks the nurse if ‘staring off into space’ is a seizure because the client ‘does that sometimes when having a seizure.’ Which response from the nurse is the most helpful?
- A. No, absence seizures can look like daydreaming or staring off into space.
- B. No, you are wrong. Don’t worry about that.
- C. Yes, so please let me know if you see the client do that.
- D. You don’t have to monitor the client for seizures.
Correct Answer: A
Rationale: Explaining that absence seizures can appear as staring or daydreaming educates the partner accurately and encourages reporting without alarm. Dismissing the concern, assuming it’s a seizure, or discouraging monitoring is unhelpful and potentially unsafe.
The client has an order for a peak to be drawn on a client receiving Garamycin. The nurse is aware that he should contact the lab for them to draw the blood:
- A. 15 minutes after the infusion
- B. 30 minutes after the infusion
- C. 1 hour after the infusion
- D. 2 hours after the infusion
Correct Answer: C
Rationale: Peak levels for gentamicin (Garamycin) are drawn 1 hour after infusion to assess maximum drug concentration and guide dosing to avoid toxicity.
The nurse is caring for a client admitted with a sickle cell crisis. What assessment finding is not consistent with the diagnosis?
- A. Enlarged liver and spleen
- B. Jaundice and icterus
- C. Decreased white blood cell count
- D. Abdominal and joint pain
Correct Answer: C
Rationale: Sickle cell crisis typically causes elevated white blood cell counts due to inflammation or infection. Hepatomegaly, jaundice, and pain are consistent findings.