Nursing Elites

1. A client has a new prescription for levothyroxine. Which of the following instructions should the nurse include?

• A. Take the medication on an empty stomach.
• B. Take the medication with food.
• C. Take the medication at bedtime.
• D. Take the medication with an antacid.

Correct answer: A

Rationale: The correct answer is A: 'Take the medication on an empty stomach.' Levothyroxine should be taken on an empty stomach to ensure optimal absorption. Food, especially high-fiber foods, can interfere with the absorption of levothyroxine. Taking it with an antacid or at bedtime may also affect its absorption. Instructing the client to take the medication on an empty stomach will help maintain consistent blood levels of levothyroxine. Choice B is incorrect as taking levothyroxine with food can reduce its absorption. Choice C is incorrect because taking levothyroxine at bedtime may lead to inconsistent blood levels due to food intake during the day. Choice D is incorrect as antacids can interfere with the absorption of levothyroxine.

2. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally?

• A. Rhonchi
• B. Crackles
• C. Wheezes
• D. Diminished breath sounds

Correct answer: B

Rationale: In this scenario, the client is exhibiting signs of pulmonary edema, which can occur as a complication of myocardial infarction. Crackles are typically heard in cases of pulmonary edema, characterized by fluid accumulation in the lungs. These crackling sounds are heard during inspiration and sometimes expiration and are an indication of fluid-filled alveoli. Therefore, when assessing the client with these symptoms, the nurse would expect to hear crackles bilaterally. Rhonchi, which are coarse rattling respiratory sounds, are typically associated with conditions like bronchitis or pneumonia, not pulmonary edema. Wheezes are high-pitched musical sounds heard in conditions like asthma or COPD, not commonly present in pulmonary edema. Diminished breath sounds suggest decreased airflow or lung consolidation, not typical findings in pulmonary edema.

3. A client admitted with coronary artery disease (CAD) reports dyspnea at rest. What intervention should the nurse prioritize?

• A. Providing a walker to aid in ambulation
• B. Elevating the head of the bed to at least 45 degrees
• C. Performing continuous monitoring of oxygen saturation
• D. Placing an oxygen cannula at the bedside for use if needed

Correct answer: B

Rationale: In a client with coronary artery disease (CAD) experiencing dyspnea at rest, the priority intervention should be to elevate the head of the bed to at least 45 degrees. This position helps reduce the work of breathing, optimizes lung expansion, and can alleviate symptoms of dyspnea by improving oxygenation and ventilation. Providing a walker for ambulation, monitoring oxygen saturation, and having an oxygen cannula at the bedside are important interventions but not the priority when the client is experiencing dyspnea at rest. Elevating the head of the bed is crucial to improve respiratory function and should be prioritized in this situation.

4. The client with a history of left-sided heart failure is exhibiting increasing shortness of breath and frothy sputum. What is the priority nursing action?

• A. Administer oxygen
• B. Encourage coughing and deep breathing
• C. Place the client in a supine position
• D. Notify the healthcare provider immediately

Correct answer: A

Rationale: Shortness of breath and frothy sputum are indicative of pulmonary edema, a serious condition that requires immediate intervention to improve oxygenation. Administering oxygen is the priority action to support the client's respiratory function and prevent further deterioration. Oxygen therapy helps increase the oxygen levels in the blood, alleviate respiratory distress, and support vital organ function. Prompt intervention with oxygen can help stabilize the client while further assessments and treatments are initiated. Encouraging coughing and deep breathing may worsen the client's condition by increasing respiratory effort. Placing the client in a supine position can further compromise breathing in a client with pulmonary edema. Notifying the healthcare provider is important but not the priority when the client's respiratory status is deteriorating.

5. A client is receiving morphine for pain. Which of the following assessments is the priority?

• A. Urine output
• B. Pupil reaction
• C. Respiratory rate
• D. Bowel sounds

Correct answer: C

Rationale: The correct answer is C: Respiratory rate. Monitoring the respiratory rate is the priority assessment for a client receiving morphine due to the risk of respiratory depression. Morphine is a potent opioid that can cause respiratory depression, which is a serious adverse effect that can be life-threatening. Assessing the client's respiratory rate is crucial to detect any signs of respiratory depression early and intervene promptly. Assessing urine output is important but not as critical as monitoring for respiratory depression with morphine. Pupil reaction and bowel sounds are also important assessments but do not take precedence over monitoring the respiratory rate when a client is on morphine.

Similar Questions