a nurse is preparing to administer a dose of levothyroxine which of the following should the nurse do
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A healthcare provider is preparing to administer a dose of levothyroxine. Which of the following should the healthcare provider do?

Correct answer: B

Rationale: The correct answer is to assess the patient's heart rate. Levothyroxine is a thyroid hormone replacement medication that can increase metabolism. One of the potential side effects of levothyroxine is tachycardia (rapid heart rate). Therefore, it is essential for the healthcare provider to assess the patient's heart rate before administering the medication to monitor for any signs of tachycardia. Giving levothyroxine with food may affect its absorption, so it is typically recommended to administer it on an empty stomach. Administering it in the evening is not necessary unless specifically prescribed by the healthcare provider, and giving it with calcium supplements can interfere with the absorption of levothyroxine.

2. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which action should the nurse take if the client develops toxicity?

Correct answer: A

Rationale: In cases of magnesium sulfate toxicity, administering calcium gluconate IV is crucial as it is the antidote for magnesium sulfate. Calcium gluconate helps reverse the effects of magnesium sulfate, especially when signs of toxicity like respiratory depression or loss of reflexes occur. Increasing the magnesium sulfate infusion would worsen toxicity. Administering IV fluids may be beneficial for hydration but does not address magnesium sulfate toxicity. Hydralazine is used to manage hypertension, not magnesium sulfate toxicity.

3. What is the first action when a client who is admitted with schizophrenia reports hearing voices telling them to harm themselves?

Correct answer: B

Rationale: The correct first action when a client with schizophrenia reports hearing voices telling them to harm themselves is to ask the client what the voices are saying. This is important to assess the content of the hallucinations and determine if there is any immediate danger or suicidal intent. Administering antipsychotic medication without knowing the content of the voices or the level of danger could be inappropriate and potentially harmful. Distracting the client with another activity may not address the underlying issue of the hallucinations commanding harm. Calling the healthcare provider can be done after assessing the situation and gathering information from the client.

4. A client tells the nurse that she suspects she is pregnant because she is able to feel the baby move. The nurse knows that this is a:

Correct answer: A

Rationale: The correct answer is A: Presumptive sign of pregnancy. Quickening, or the sensation of fetal movement, is considered a presumptive sign of pregnancy. It is not definitive because other conditions, such as gas or intestinal movement, can mimic the feeling of fetal movement. Choice B, Probable sign of pregnancy, refers to signs that make the nurse reasonably certain that a woman is pregnant, such as a positive pregnancy test. Choice C, Positive sign of pregnancy, includes signs like hearing fetal heart tones or visualizing the fetus on ultrasound, which definitively confirm pregnancy. Choice D, Possible sign of pregnancy, is a vague term and does not specifically relate to any pregnancy sign.

5. A client with chronic renal failure needs dietary instructions. Which of the following should the nurse provide?

Correct answer: C

Rationale: The correct answer is to instruct the client to restrict protein intake. In chronic renal failure, the kidneys are unable to effectively filter waste products, so limiting protein helps reduce the buildup of waste in the body. Increasing calcium intake (Choice A) is not typically necessary unless there is a specific deficiency. Providing a diet high in potassium (Choice B) is contraindicated as potassium levels need to be monitored and controlled in renal failure. Increasing fluid intake (Choice D) may be necessary depending on the individual's condition, but restricting protein intake is a more critical dietary instruction for clients with chronic renal failure.

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