Nursing Elites

1. A client with a new prescription for levothyroxine is receiving teaching from a nurse. Which statement indicates understanding of the teaching?

• A. I should take this with food
• B. I will see immediate results
• C. I might not realize the full effect of the medication for several weeks
• D. I should stop if I feel better

Correct answer: C

Rationale: The correct answer is C: 'I might not realize the full effect of the medication for several weeks.' Levothyroxine is a medication that may take several weeks for the full effect to be evident. Choice A is incorrect because levothyroxine should be taken on an empty stomach. Choice B is incorrect because immediate results are not expected with levothyroxine. Choice D is incorrect because stopping the medication without consulting a healthcare provider can be harmful, even if the client feels better.

2. What is the nurse's priority intervention for a patient who has developed a pressure ulcer?

• A. Apply a dressing to the ulcer.
• B. Reposition the patient every 2 hours.
• C. Provide the patient with pain medication.
• D. Clean the ulcer with normal saline.

Correct answer: B

Rationale: The correct answer is to reposition the patient every 2 hours. Repositioning helps prevent the worsening of pressure ulcers by relieving pressure on affected areas and promoting blood circulation, which aids in healing. Applying a dressing (choice A) is important but not the priority compared to repositioning. Providing pain medication (choice C) is essential for comfort but does not address the root cause of the pressure ulcer. Cleaning the ulcer with normal saline (choice D) is part of wound care but does not take precedence over repositioning to prevent further tissue damage.

3. A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse assess first?

• A. A client who has urolithiasis and reports severe ankle pain extending toward the abdomen
• B. A client who has acute cholecystitis and reports abdominal pain radiating to the right shoulder
• C. A client who has had a total knee arthroplasty, is 1 day postoperative, and reports a pain level of 8 on a 0 to 10 pain scale
• D. A client who has a fractured femur and reports sudden sharp chest pain

Correct answer: D

Rationale: The correct answer is D because a client with a fractured femur and sudden chest pain may be experiencing a pulmonary embolism, which requires immediate assessment. Choice A is incorrect because although severe pain is present, it is more indicative of musculoskeletal issues related to urolithiasis rather than a life-threatening condition. Choice B, related to acute cholecystitis, is less urgent than choice D as the pain radiating to the right shoulder is a common symptom but does not indicate an immediate life-threatening situation. Choice C, regarding a client post-total knee arthroplasty with a pain level of 8, is important but not as urgent as a potential pulmonary embolism in choice D.

4. A patient recovering from a stroke has difficulty swallowing. Which action should the nurse prioritize?

• A. Begin feeding the patient soft solids.
• B. Place the patient on NPO (nothing by mouth) status.
• C. Provide ice chips to help soothe the throat.
• D. Start the patient on a clear liquid diet.

Correct answer: B

Rationale: The correct answer is to place the patient on NPO (nothing by mouth) status. Patients recovering from a stroke with difficulty swallowing are at high risk for aspiration, which can lead to serious complications like aspiration pneumonia. Therefore, the priority is to keep the patient on NPO until a thorough evaluation by a healthcare provider is completed. Choice A is incorrect as feeding the patient soft solids can increase the risk of aspiration. Choice C is incorrect as providing ice chips may further compromise swallowing safety. Choice D is incorrect as starting the patient on a clear liquid diet can also increase the risk of aspiration in this scenario.

5. What is the most important nursing intervention when caring for a patient with a wound?

• A. Apply an occlusive dressing over the wound.
• B. Clean the wound with normal saline.
• C. Administer antibiotics as prescribed.
• D. Reassess the wound every 4 hours for changes.

Correct answer: B

Rationale: The most important nursing intervention when caring for a patient with a wound is to clean the wound with normal saline. This is crucial for preventing infection and promoting healing. Applying an occlusive dressing (Choice A) can be important but should come after cleaning the wound. Administering antibiotics (Choice C) is not the first-line intervention for all wounds and should be based on the healthcare provider's prescription. Reassessing the wound (Choice D) is essential but not the most important initial intervention.

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