Nokea
The nurse is reinforcing teaching for a client who has a new prescription for levothyroxine. Which of the following information should the nurse reinforce?
- A. Discontinue the medication if you become pregnant.
- B. Take the medication at bedtime to decrease drowsiness.
- C. Notify your health care provider if you experience palpitations.
- D. Take the medication with a snack if you experience an upset stomach.
Correct Answer: C
Rationale: Palpitations may indicate levothyroxine overdose or hyperthyroidism, requiring prompt reporting to adjust the dose or evaluate thyroid function.
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A newborn had a bowel resection with temporary colostomy for Hirschsprung disease. The practical nurse should alert the supervising registered nurse about which postoperative finding?
- A. Moderate amount of blood-tinged mucus from the stoma on postoperative day 2
- B. Small amount of non-formed stool in the colostomy bag on postoperative day 6
- C. Stoma bleeds a small amount during colostomy bag change on postoperative day 3
- D. Stoma is gray-tinged at the edges but pink at the center on postoperative day 5
Correct Answer: D
Rationale: A gray-tinged stoma suggests ischemia or poor perfusion, which is a critical finding requiring immediate reporting to assess for stoma viability.
The nurse is preparing to assist a client to ambulate to the bathroom. The client rises from the chair at the bedside and immediately reports feeling dizzy. It would be a priority for the nurse to
- A. Check the client's orthostatic blood pressure
- B. encourage the client to remain on bed rest
- C. apply a gait belt around the client's waist
- D. assist the client back to a sitting position
Correct Answer: D
Rationale: Dizziness upon standing suggests orthostatic hypotension or other instability. Assisting the client back to a sitting position prevents falls and ensures immediate safety.
A 6-year old is admitted with a diagnosis of childhood autism. Which behavior is most typical of the child with autism?
- A. A willingness to talk to strangers
- B. A disinterest in inanimate objects
- C. Engaging in ritualistic behavior
- D. A dislike of music
Correct Answer: C
Rationale: Children with autism often engage in ritualistic or repetitive behaviors, such as specific routines or movements, as a hallmark of the condition. Choice A is incorrect because children with autism typically have social communication difficulties and are less likely to engage with strangers. Choice B is incorrect as they may show intense interest in specific inanimate objects. Choice D is incorrect as music preference varies and is not a defining characteristic.
While the nurse is preparing medications, a code occurs. One of the nursing assistants offers to help by administering the medications. What is the best response by the nurse?
- A. Allow the nursing assistant to give the medications
- B. Hold the medications until after the code
- C. Give the medications and then help with the code
- D. Ask the nursing assistant when she was checked off on giving medications
Correct Answer: B
Rationale: Holding medications prioritizes the code response, as CNAs cannot administer medications, ensuring patient safety and appropriate task delegation.
A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene?
- A. Encourages the client to drink extra fluids while taking ferrous sulfate
- B. Offers the client orange juice for administration of ferrous sulfate
- C. Plans to administer ferrous sulfate one hour before breakfast
- D. Prepares to administer a prescribed calcium supplement with ferrous sulfate
Correct Answer: D
Rationale: Calcium inhibits iron absorption, so administering ferrous sulfate with a calcium supplement reduces its effectiveness, requiring intervention.