Nursing Elites

1. A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication dosage is too high?

• A. Increased sensitivity to cold.
• B. Increased heart rate and palpitations.
• C. Improved energy levels.
• D. Improved tolerance to heat.

Correct answer: B

Rationale: The correct answer is B: Increased heart rate and palpitations. When a client with hypothyroidism is prescribed levothyroxine, these symptoms may indicate that the dosage is too high, causing the client to develop hyperthyroidism. Choices A, C, and D are incorrect. Increased sensitivity to cold is a symptom of hypothyroidism, improved energy levels are an expected outcome of levothyroxine therapy for hypothyroidism, and improved tolerance to heat is not a common sign of levothyroxine overdose.

2. A client has been receiving hydromorphone every six hours for four days. What assessment should the nurse prioritize?

• A. Increase the dosage of the medication.
• B. Auscultate bowel sounds.
• C. Monitor the client's blood pressure.
• D. Check the client's respiratory rate.

Correct answer: B

Rationale: The correct answer is B. Hydromorphone can cause constipation, a common side effect of opioids. Therefore, it is crucial to auscultate bowel sounds to monitor for signs of decreased gastrointestinal motility. Monitoring blood pressure (choice C) and respiratory rate (choice D) are important but not the priority in this scenario as constipation is a common issue with opioid use. Increasing the dosage of the medication (choice A) is not appropriate without assessing the client's bowel function first.

3. The nurse is caring for a client who has COPD and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD?

• A. Administering narcotics for pain relief
• B. Encouraging the client to increase fluid intake
• C. Applying oxygen therapy at a high flow rate
• D. Assisting the client with deep breathing exercises

Correct answer: C

Rationale: The correct answer is C: Applying oxygen therapy at a high flow rate. In clients with COPD, high levels of supplemental oxygen can suppress the hypoxic drive to breathe, leading to carbon dioxide retention and respiratory depression. Oxygen therapy must be administered cautiously to prevent worsening respiratory status. Administering narcotics for pain relief (Choice A) can be necessary but should be done judiciously. Encouraging fluid intake (Choice B) and assisting with deep breathing exercises (Choice D) are generally beneficial interventions for clients with COPD and should not require the same level of caution as high-flow oxygen therapy.

4. The nurse is caring for a client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which intervention is most important for the nurse to implement?

• A. Encourage oral hydration
• B. Monitor for signs of dehydration
• C. Restrict fluid intake
• D. Administer IV fluids as prescribed

Correct answer: C

Rationale: In SIADH, there is excessive ADH secretion leading to water retention and dilutional hyponatremia. The most crucial intervention is to restrict fluid intake to prevent further fluid overload and worsening of hyponatremia. Encouraging oral hydration (choice A) would exacerbate the condition by adding more fluids. Monitoring for signs of dehydration (choice B) is not appropriate as the client is at risk of fluid overload. Administering IV fluids (choice D) would worsen the hyponatremia and should be avoided.

5. A client with multiple sclerosis is receiving intravenous methylprednisolone. What is the nurse's priority action?

• A. Monitor blood glucose levels every 6 hours.
• B. Monitor for signs of infection.
• C. Encourage increased oral fluid intake.
• D. Check the client's temperature every 4 hours.

Correct answer: B

Rationale: When a client with multiple sclerosis is receiving intravenous methylprednisolone, the nurse's priority action is to monitor for signs of infection. Corticosteroids like methylprednisolone can suppress the immune system, increasing the risk of infection. Monitoring for signs of infection allows for early detection and prompt intervention. Monitoring blood glucose levels may be important in clients receiving corticosteroids for prolonged periods, but it is not the priority in this case. Encouraging increased oral fluid intake is generally beneficial but not the priority over monitoring for infection. Checking the client's temperature is important but not the priority action compared to monitoring for signs of infection.

Similar Questions