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. Which intervention is most effective for managing a patient with constipation?

• A. Increase the patient's fluid intake.
• B. Administer a stool softener as prescribed.
• C. Provide the patient with a high-fiber diet.
• D. Teach the patient to perform Valsalva maneuvers.

Correct answer: B

Rationale: The most effective intervention for managing constipation in a patient is to administer a stool softener as prescribed. Stool softeners help relieve constipation by making the stool easier to pass, especially in postoperative patients. Increasing fluid intake can be beneficial but may not address the underlying cause of constipation. While a high-fiber diet is important for bowel health, it may not provide immediate relief for constipation. Teaching a patient to perform Valsalva maneuvers is not recommended for managing constipation as it can lead to adverse effects like increasing intra-abdominal pressure.

3. After unsuccessful alternatives, a patient requires restraints. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care?

• A. The health care provider writes the type and location of the restraint.
• B. The health care provider renews orders for restraints every 24 hours.
• C. The health care provider performs a face-to-face assessment prior to the order.
• D. The health care provider orders restraints PRN (as needed).

Correct answer: A

Rationale: In the context of restraining a patient, it is crucial for the health care provider to specify the type and location of the restraint in the order to ensure the safety and well-being of the patient. This information helps guide the nursing staff in the safe application of restraints. Renewing orders every 24 hours ensures that the need for restraints is continually assessed, promoting patient safety. Performing a face-to-face assessment before ordering restraints allows for a thorough evaluation of the patient's condition and the necessity of using restraints. Ordering restraints PRN (as needed) is not appropriate for safe care as it lacks specificity and may lead to inconsistent application and monitoring.

4. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

• A. Cleanse the bag every 24 hours
• B. Cleanse the bag every 48 hours
• C. Use tap water
• D. Flush the tube every 4 hours

Correct answer: A

Rationale: The correct answer is A. Cleansing the bag every 24 hours can lead to contamination, increasing the risk of infection and diarrhea. Using tap water (choice C) is not recommended for cleaning the gastrostomy tube due to the risk of introducing harmful microorganisms. Cleansing the bag every 48 hours (choice B) is not frequent enough and may also contribute to infection. Flushing the tube every 4 hours (choice D) is a standard practice to ensure patency and should not be intervened by the nurse.

5. The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?

• A. I should call 911 if my grandchild loses consciousness.
• B. Never induce vomiting if my grandchild drinks bleach.
• C. If my grandchild eats a plant, I should provide syrup of ipecac.
• D. The number for poison control is 800-222-1222.

Correct answer: C

Rationale: The correct answer is C. Administering syrup of ipecac is no longer recommended in cases of poisoning. This is because it can lead to complications and is not considered safe. The grandparent should be informed that syrup of ipecac should not be given to a child who has ingested a toxic substance. Choices A, B, and D provide accurate information regarding actions to take in case of poisoning, such as calling 911 if the child loses consciousness, not inducing vomiting if the child drinks bleach, and having the poison control number readily available.

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