Nursing Elites

1. A nurse is caring for a client with hypothyroidism. Which of the following findings indicates that the client is experiencing an adverse effect from the prescribed levothyroxine?

• A. Tachycardia
• B. Bradycardia
• C. Weight loss
• D. Increased appetite

Correct answer: A

Rationale: Tachycardia is the correct answer as it is an adverse effect of levothyroxine. Levothyroxine is a medication used to treat hypothyroidism by supplementing the body with thyroid hormone. Tachycardia, or a fast heart rate, can indicate an overdosage or increased sensitivity to levothyroxine. Bradycardia, slow heart rate, weight loss, and increased appetite are not typically associated with adverse effects of levothyroxine. Bradycardia may actually be a symptom of untreated hypothyroidism.

2. A nurse is reviewing the medication class benzodiazepines. The nurse would use caution when administering benzodiazepines to which of the below clients?

• A. A client with glaucoma
• B. A client with renal failure
• C. A client with hypertension
• D. A client with insomnia

Correct answer: A

Rationale: The correct answer is A. Benzodiazepines should be used cautiously in clients with glaucoma because these medications can increase intraocular pressure. Choices B, C, and D are incorrect because renal failure, hypertension, and insomnia are not contraindications for administering benzodiazepines.

3. A client with an artificial heart valve is prescribed warfarin therapy. Which of the following laboratory values should the nurse monitor to assess the therapeutic effect of warfarin?

• A. Hemoglobin (Hgb)
• B. Prothrombin time (PT)
• C. Bleeding time
• D. Activated partial thromboplastin time (aPTT)

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT). Warfarin is an anticoagulant medication that works by inhibiting the clotting factors dependent on vitamin K, such as factors II, VII, IX, and X. The prothrombin time (PT) measures the extrinsic pathway and is used to monitor the therapeutic effects of warfarin therapy. Monitoring PT helps assess the time it takes for the blood to clot, ensuring that the anticoagulant effect is within the desired range. Choices A, C, and D are incorrect because hemoglobin (Hgb) measures the amount of hemoglobin in the blood, bleeding time assesses the time it takes for bleeding to stop, and activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin therapy.

4. A nurse is caring for a client receiving IV vancomycin. The nurse notes flushing of the client's neck and chest. Which of the following actions should the nurse take?

• A. Stop the infusion
• B. Document the findings as a harmless reaction
• C. Slow the infusion rate
• D. Administer diphenhydramine

Correct answer: C

Rationale: The correct action for the nurse to take when a client receiving IV vancomycin shows flushing of the neck and chest is to slow the infusion rate. Flushing is a common sign of Red Man Syndrome, which is associated with rapid infusions of vancomycin. Slowing down the infusion rate can help prevent further flushing and the development of Red Man Syndrome. Stopping the infusion (Choice A) may be too drastic if the symptoms are mild and can be managed by slowing the rate. Documenting the findings as a harmless reaction (Choice B) is incorrect because flushing should be addressed promptly to prevent complications. Administering diphenhydramine (Choice D) is not the initial or best intervention for flushing associated with vancomycin; slowing the infusion rate is the priority.

5. A client is prescribed digoxin 0.125 mg daily for heart failure. Which of the following client reports should concern the nurse as a sign of digoxin toxicity?

• A. Increased appetite
• B. Visual disturbances
• C. Weight gain
• D. Constipation

Correct answer: B

Rationale: Visual disturbances such as blurred vision or seeing halos around lights are common signs of digoxin toxicity. Increased appetite, weight gain, and constipation are not typically associated with digoxin toxicity. Weight gain could be a sign of worsening heart failure rather than digoxin toxicity. Increased appetite and constipation are not specific signs of digoxin toxicity and are less likely to be related.

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