Nursing Elites

1. A nurse is providing teaching to a client who has a new prescription for levothyroxine. Which of the following statements should the nurse include?

• A. Take this medication with food to prevent gastrointestinal upset.
• B. Take this medication in the morning to prevent insomnia.
• C. You may experience weight gain while taking this medication.
• D. You should avoid eating foods that contain iodine.

Correct answer: B

Rationale: The correct answer is B. Instructing the client to take levothyroxine in the morning is important to prevent insomnia, a common side effect of this medication. Choice A is incorrect as levothyroxine should be taken on an empty stomach. Choice C is inaccurate because weight loss, not weight gain, is a potential side effect of levothyroxine. Choice D is not necessary as clients do not need to avoid foods containing iodine while taking levothyroxine.

2. A nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?

• A. Flush the tube with 30 mL of sterile water before each feeding.
• B. Check for gastric residuals every 4 hours.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Place the client in the left lateral position during feedings.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.

3. A nurse is reviewing the laboratory results of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse report to the provider?

• A. White blood cell count 6,000/mm3
• B. Positive antinuclear antibody (ANA) titer
• C. Platelet count 220,000/mm3
• D. Blood urea nitrogen (BUN) 15 mg/dL

Correct answer: B

Rationale: A positive antinuclear antibody (ANA) titer is a significant finding in clients with systemic lupus erythematosus (SLE) as it indicates active disease. This result should be reported to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and not specifically indicative of disease activity in SLE. Therefore, they do not require immediate reporting to the provider.

4. A nurse is reviewing the medical record of a client who is 24 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate 90/min
• B. Serosanguineous drainage in the surgical drain
• C. Temperature 38.6°C (101.5°F)
• D. Urinary output 60 mL/hr

Correct answer: C

Rationale: The correct answer is C. A temperature of 38.6°C (101.5°F) is above the normal range and indicates a fever, which is a concerning finding postoperatively. Fever can be a sign of infection, so the nurse should report this finding to the provider for further evaluation and intervention. Choices A, B, and D are within expected parameters for a client who is 24 hours postoperative following abdominal surgery and do not require immediate reporting. A heart rate of 90/min, serosanguineous drainage in the surgical drain, and a urinary output of 60 mL/hr are all common postoperative findings that do not raise immediate concerns.

5. While caring for a newborn under phototherapy lights, which of the following is an appropriate nursing action?

• A. Ensure the eye shield is covering the eyes.
• B. Apply lotion to the exposed skin.
• C. Offer glucose water between feedings.
• D. Discontinue breastfeeding during treatment.

Correct answer: A

Rationale: The correct answer is to ensure the eye shield is covering the eyes. Protecting the newborn's eyes from exposure to direct light is crucial during phototherapy to prevent potential eye damage. Applying lotion to the exposed skin (choice B) is not recommended as it can interfere with the effectiveness of the phototherapy. Offering glucose water between feedings (choice C) is not necessary and may not be suitable for a newborn undergoing treatment. Discontinuing breastfeeding during treatment (choice D) is not recommended as breast milk provides essential nutrients and hydration for the newborn, and breastfeeding should continue unless contraindicated by a specific medical condition.

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