Nokea
The nurse is teaching a client with a new diagnosis of hyperthyroidism about methimazole (Tapazole). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any fever or sore throat.
- C. Stop the medication if thyroid levels normalize.
- D. Avoid regular thyroid function Test s.
Correct Answer: B
Rationale: Fever or sore throat may indicate agranulocytosis, a serious methimazole side effect. Options A, C, and D are incorrect.
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The multidisciplinary team decides to implement behavior modification with a client.
- A. What is the primary nursing action during implementation of behavior modification?
- B. Confirm that all staff members understand and comply with the treatment plan.
- C. Establish mutually agreed upon, realistic goals.
- D. Ensure that the potent recorders (rewards) are important to the client.
- E. Establish a fixed interval schedule for reinforcement.
Correct Answer: A
Rationale: Consistency in applying the behavior modification plan is critical for success. Confirming that all staff members understand and comply ensures consistent implementation, reducing manipulation by the client or staff. While setting goals, choosing rewards, and scheduling reinforcement are important, they are secondary to ensuring staff alignment.
The licensed practical nurse is assisting the RN with preparation for administering a transfusion of whole blood. Which action by the nurse predisposes the client to the development of hyperkalemia?
- A. Allowing the blood to warm to room temperature
- B. Administering blood that is 24 hours old
- C. Administering blood with an 18-gauge needle
- D. Filling the drip chamber below the level of the filter
Correct Answer: A
Rationale: Allowing blood to warm to room temperature can cause red blood cells to hemolyze, releasing potassium and increasing the risk of hyperkalemia.
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
- A. The restraints/seclusion policies set forth by the institution.
- B. The patient’s competence.
- C. The patient’s voluntary/involuntary status.
- D. The patient’s nursing care plan.
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.
A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
- A. Aspiration noted on honey thick diet.
- B. Pain with a bowel movement
- C. Pain felt in the left upper quadrant
- D. Right shoulder pain
Correct Answer: B
Rationale: Bowel movement pain should be examined with a colonoscopy not an endoscopy.
A woman is in the clinic complaining of urinary frequency, urgency, and pain on urination. Orders include a urine for culture and administration of sulfisoxazole (Gantrisin) and phenazopyridine (Pyridium.) Which action should the nurse take first?
- A. Obtain a clean catch urine from the client.
- B. Ask the client if she is allergic to sulfa drugs.
- C. Administer the sulfisoxazole (Gantrisin).
- D. Administer the phenazopyridine (Pyridium).
Correct Answer: B
Rationale: Checking for sulfa allergies is critical before administering sulfisoxazole, as allergies can cause severe reactions, prioritizing safety.