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1. A patient with hyperthyroidism is prescribed propylthiouracil (PTU). What is the primary purpose of this medication?
- A. Increase thyroid hormone production
- B. Suppress thyroid hormone production
- C. Enhance iodine absorption
- D. Stimulate the thyroid gland
Correct answer: B
Rationale: Propylthiouracil (PTU) is a medication used to treat hyperthyroidism by suppressing the production of thyroid hormones. It works by inhibiting the enzyme responsible for the synthesis of thyroid hormones, thereby reducing their levels in the body. This helps to alleviate the symptoms of hyperthyroidism and restore thyroid hormone levels to normal range.
2. When covering another nurse's assignment during a lunch break, based on the status report provided, which client should the charge nurse check first?
- A. The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dl.
- B. The client with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch.
- C. The client post-triple coronary bypass four days ago who has serosanguinous drainage in the chest tube.
- D. The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.
Correct answer: D
Rationale: The client with a pneumothorax and a pulse oximeter reading of 90% indicates potential respiratory compromise, requiring immediate attention to prevent further deterioration.
3. When a client reports being allergic to penicillin, which question should the nurse ask to gather more information?
- A. Are you allergic to any other medications?
- B. How often have you taken penicillin in the past?
- C. Is anyone else in your family allergic to penicillin?
- D. What happens to you when you take penicillin?
Correct answer: D
Rationale: Questioning the client about the specific allergic reaction to penicillin is crucial for assessing the severity and type of allergic response, aiding in determining appropriate treatment and avoiding potential adverse reactions.
4. An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?
- A. This behavior can be considered sexual harassment and should be reported to the administration immediately.
- B. The UAP should be reassigned to another group of residents, preferably females only.
- C. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need.
- D. The resident needs to understand the rules regarding unwanted touching of the staff and the consequences.
Correct answer: C
Rationale: In this scenario, the resident's actions of reaching for the UAP's hand and trying to kiss it could indicate a need for touch rather than intentional sexual harassment. The best assessment is to consider the possibility that the client may be experiencing touch deprivation and is seeking appropriate ways to express his need for physical contact. Providing guidance on acceptable ways to seek physical affection can help address the underlying issue and improve the resident's interactions with the staff. Choice A is incorrect because assuming sexual harassment without understanding the context and potential reasons behind the behavior can lead to misinterpretation. Choice B is inappropriate as reassignment based on gender is not a solution and does not address the root cause of the behavior. Choice D is not the best approach as it focuses solely on setting boundaries without considering the resident's underlying need for touch.
5. What skin care instructions should the nurse give to a patient receiving external beam radiation therapy for cancer treatment?
- A. Use a heating pad to relieve any pain in the treated area.
- B. Apply alcohol-based lotions to the treated area daily.
- C. Avoid exposing the treated area to sunlight.
- D. Wash the treated area with hot water and strong soap.
Correct answer: C
Rationale: Patients undergoing external beam radiation therapy should be advised to avoid exposing the treated area to sunlight to prevent further skin damage. Heat sources like heating pads should be avoided to prevent burns and irritation to the skin. Alcohol-based lotions can be irritating to the skin and are not recommended. Washing the treated area with lukewarm water and mild soap is preferable to maintain skin integrity and prevent irritation. Therefore, the correct instruction for the patient is to avoid exposing the treated area to sunlight.
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