Nursing Elites

1. What symptoms suggest the dosage of levothyroxine sodium is too high in a 26-year-old client with simple goiter?

• A. Bradycardia and constipation.
• B. Palpitations and shortness of breath.
• C. Lethargy and lack of appetite.
• D. Muscle cramps and dry skin.

Correct answer: B

Rationale: The correct answer is B: Palpitations and shortness of breath. These symptoms suggest excessive thyroid hormone levels, indicating that the levothyroxine dose is too high. Bradycardia and constipation (choice A) are more indicative of hypothyroidism, which occurs when thyroid hormone levels are low. Lethargy and lack of appetite (choice C) are also common symptoms of hypothyroidism. Muscle cramps and dry skin (choice D) can be associated with various conditions but are not specific to a high dosage of levothyroxine.

2. What safety measure should the nurse take for a client with a seizure disorder who has an IV line?

• A. Ensure that the IV site is padded and protected.
• B. Limit the client's mobility to prevent dislodging the IV.
• C. Place the IV site on the same side as the seizure activity.
• D. Ensure the client is positioned on the opposite side of the IV line.

Correct answer: D

Rationale: The correct answer is D: Ensure the client is positioned on the opposite side of the IV line. Placing the IV line on the opposite side of any seizure activity is essential to prevent injury. It helps to ensure that the IV line is not dislodged during a seizure. Choices A, B, and C are incorrect. While padding and protecting the IV site is important, the priority is to position the client on the side opposite to the IV line to prevent dislodgement and injury during a seizure.

3. The nurse is caring for a client post-surgery with an order to ambulate the client every 2 hours. Which of the following tasks could be safely delegated to an unlicensed assistive personnel (UAP)?

• A. Assessing the client's ability to ambulate safely
• B. Documenting the client's tolerance of ambulation
• C. Assisting the client with ambulation
• D. Evaluating the client's pain level after ambulation

Correct answer: C

Rationale: Assisting with ambulation is a task that can be safely delegated to a UAP as it is a supportive activity that does not require clinical judgment. Choices A, B, and D involve assessments, documentation, and evaluation, which require nursing knowledge and clinical judgment, making them tasks that should be performed by a licensed nurse.

4. The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor?

• A. Bowel sounds
• B. Heart rate
• C. Arterial blood gases
• D. Apnea episodes

Correct answer: C

Rationale: Corrected Rationale: Surfactant therapy is used to improve lung function and gas exchange in premature infants with respiratory distress. Monitoring arterial blood gases is essential to assess the effectiveness of the treatment and ensure adequate oxygenation. While monitoring heart rate is important in neonatal care, assessing arterial blood gases will provide direct information regarding the infant's oxygenation status post-surfactant administration. Bowel sounds are not directly related to the respiratory distress symptoms described, and monitoring apnea episodes, although important in preterm infants, is not the most crucial assessment immediately following surfactant administration.

5. A client presents with a suspected infection and has a fever of 102°F. What is the nurse's immediate priority?

• A. Administer antipyretics as ordered
• B. Take a blood culture before administering antibiotics
• C. Encourage fluid intake to prevent dehydration
• D. Monitor vital signs every hour

Correct answer: B

Rationale: The immediate priority for a client with a suspected infection and fever is to take a blood culture before administering antibiotics. This step is crucial to identify the causative organism and ensure appropriate treatment. Administering antipyretics or encouraging fluid intake are important but should come after obtaining the blood culture to avoid interfering with test results. Monitoring vital signs, although essential, is not the immediate priority compared to identifying the infectious agent.

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