Nursing Elites

1. A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) and reports aching in his right foot. Which intervention is most important for the nurse to implement?

• A. Encourage discussion about feelings of limb loss.
• B. Administer a prescription for gabapentin.
• C. Teach the client how to wrap the stump with an elastic bandage.
• D. Offer assistance to move to a quiet room to relax.

Correct answer: B

Rationale: The correct answer is B: Administer a prescription for gabapentin. Gabapentin is used to treat phantom limb pain, which is common after amputations. Encouraging discussion about feelings of limb loss (choice A) is important for emotional support but does not address the physical pain. Teaching the client how to wrap the stump with an elastic bandage (choice C) is not indicated for aching in the 'right foot' as described. Offering assistance to move to a quiet room to relax (choice D) may provide comfort but does not address the underlying issue of phantom limb pain.

2. A client with hypothyroidism is prescribed levothyroxine. What is the most important teaching point for the nurse to provide?

• A. Take the medication with food to avoid stomach upset.
• B. Take the medication at the same time every day to maintain consistent thyroid levels.
• C. Expect increased sensitivity to cold as a side effect of the medication.
• D. Increase the dosage of levothyroxine if symptoms worsen.

Correct answer: B

Rationale: The correct answer is B. Levothyroxine should be taken at the same time every day to maintain stable thyroid hormone levels and ensure effective management of hypothyroidism. Consistent dosing is critical for preventing fluctuations in hormone levels. Choice A is incorrect because levothyroxine is usually recommended to be taken on an empty stomach for optimal absorption. Choice C is incorrect because increased sensitivity to cold is not a common side effect of levothyroxine. Choice D is incorrect because adjusting the dosage without healthcare provider guidance can be dangerous and should not be done independently.

3. A client with tuberculosis (TB) is being discharged on isoniazid and rifampin. What instruction should the nurse prioritize?

• A. Complete the full course of antibiotics.
• B. Notify the healthcare provider if you experience tingling in your fingers.
• C. Use a disposable mask when in contact with others.
• D. Monitor liver function tests monthly.

Correct answer: C

Rationale: The correct answer is to instruct the client to use a disposable mask when in contact with others. TB is highly contagious, and wearing a mask can help prevent the spread of the disease to others. Choice A is important but not the priority as using a mask directly impacts public health. Choice B is related to a potential side effect of isoniazid, peripheral neuropathy, but immediate healthcare provider notification is not required. Choice D is relevant due to the potential hepatotoxicity of isoniazid and rifampin, but it is not the priority instruction in this scenario.

4. An unresponsive male victim of a diving accident is brought to the emergency department where immediate surgery is required to save his life. No family members are available. What action should the nurse take first?

• A. Ask the friend to sign an informed consent.
• B. Notify the unit manager that a court order is needed.
• C. Continue providing life support until a guardian is found.
• D. Proceed with surgery preparation without consent.

Correct answer: D

Rationale: In emergency situations where immediate surgery is required to save a patient's life and no family members are available, consent can be waived to proceed with necessary interventions. The priority in this scenario is to proceed with surgery preparation without waiting for consent, as any delay could jeopardize the patient's life. Asking the friend to sign informed consent or notifying the unit manager for a court order would cause unnecessary delays, which are not advisable in this critical situation. Continuing life support until a guardian is found is not the most appropriate action when immediate surgical intervention is necessary.

5. A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

• A. Somnambulism
• B. Dry mouth
• C. Vivid dreams
• D. Daytime sleepiness

Correct answer: A

Rationale: The correct answer is A, 'Somnambulism' (sleepwalking). Somnambulism is a potentially dangerous side effect that should be reported to the healthcare provider immediately. Sleepwalking can pose risks to the individual's safety and may indicate a serious adverse reaction to the medication. Dry mouth (choice B), vivid dreams (choice C), and daytime sleepiness (choice D) are common side effects of ramelteon and are generally not considered as urgent or serious as somnambulism. While these side effects can impact the client's quality of life, they are not typically associated with immediate safety concerns.

Similar Questions