Nursing Elites

1. A nurse is reviewing the medical record of a client who has hypothyroidism. Which of the following findings should the nurse expect?

• A. Weight gain of 1.4 kg (3 lb) in the past 2 weeks.
• B. Exophthalmos.
• C. Tachycardia.
• D. Heat intolerance.

Correct answer: A

Rationale: The correct answer is A. Weight gain can indicate myxedema, which is a symptom commonly seen in hypothyroidism. Exophthalmos (choice B) is actually a characteristic finding of hyperthyroidism, not hypothyroidism. Tachycardia (choice C) and heat intolerance (choice D) are also more indicative of hyperthyroidism rather than hypothyroidism.

2. How should pain be assessed in a non-verbal patient?

• A. Observe facial expressions
• B. Use the Wong-Baker faces scale
• C. Assess heart rate
• D. Ask the patient to rate their pain

Correct answer: A

Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.

3. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report?

• A. Calcium level of 9.0 mg/dL
• B. Serum sodium level of 138 mEq/L
• C. Respiratory rate of 18/min
• D. Stridor

Correct answer: D

Rationale: Stridor is a high-pitched sound that indicates airway obstruction and is the priority finding to report following a thyroidectomy. In this situation, airway compromise is a critical concern that requires immediate intervention to ensure adequate oxygenation. While calcium level (Choice A) and serum sodium level (Choice B) are important assessments post-thyroidectomy, they do not represent an immediate threat to the client's airway. A respiratory rate of 18/min (Choice C) falls within the normal range and does not indicate an immediate risk to the client's airway compared to the presence of stridor.

4. Which of the following lab values indicates a patient on warfarin is at a therapeutic level?

• A. INR of 1.1
• B. PT of 12 seconds
• C. INR of 2.5
• D. Platelet count of 150,000

Correct answer: C

Rationale: An INR of 2.5 indicates a therapeutic level for a patient on warfarin. The INR (International Normalized Ratio) is the most accurate way to monitor and adjust warfarin doses. An INR of 1.1 (Choice A) is below the therapeutic range, indicating a need for an increased dose. PT (Prothrombin Time) of 12 seconds (Choice B) is not specific for warfarin therapy monitoring. Platelet count (Choice D) is not directly related to monitoring warfarin therapy.

5. A client at 10 weeks of gestation reports frequent nausea and vomiting. Which of the following instructions should the nurse include?

• A. Eat high-protein foods.
• B. Lie down after meals.
• C. Drink water with meals.
• D. Eat dry carbohydrates before getting out of bed.

Correct answer: D

Rationale: During early pregnancy, nausea and vomiting are common. Instructing the client to eat dry carbohydrates like crackers before getting out of bed can help alleviate these symptoms. This recommendation helps prevent an empty stomach, which can worsen nausea. High-protein foods (Choice A) may be harder to digest and could exacerbate nausea. Lying down after meals (Choice B) may increase gastric reflux and worsen symptoms. Drinking water with meals (Choice C) may make the client feel fuller, potentially worsening nausea.

Similar Questions