the healthcare provider prescribes a sedative for a client with severe hypothyroidism what is the best action for the nurse to take
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet Capstone

1. The healthcare provider prescribes a sedative for a client with severe hypothyroidism. What is the best action for the nurse to take?

Correct answer: A

Rationale: The correct answer is to affirm the nurse's plan to review the prescription with the provider. Sedatives can worsen symptoms of hypothyroidism, so it is crucial to ensure the safety of the prescribed medication. Administering the sedative without further consultation could lead to adverse effects. Simply advising the nurse to administer the medication without addressing the need for review is not the best course of action. Offering to administer the medication without proper assessment or consulting the provider is not appropriate and could potentially harm the client.

2. A client admitted with left-sided heart failure presents with shortness of breath and pink frothy sputum. Which assessment finding requires immediate intervention?

Correct answer: C

Rationale: Correct Answer: Pink frothy sputum and increased respiratory rate. Pink frothy sputum is a sign of pulmonary edema, indicating fluid in the lungs, a life-threatening condition that requires immediate intervention to prevent respiratory failure. Increased respiratory rate is also concerning as it indicates the body's effort to compensate for the decreased oxygenation. Options A, B, and D are not the most critical findings in this situation. Decreased breath sounds bilaterally may indicate a pneumothorax or atelectasis, heart rate of 110 bpm and irregular rhythm can be managed with medications and further assessment, and elevated blood pressure with shortness of breath is not as urgent as pink frothy sputum and increased respiratory rate.

3. When assessing a client with a diagnosis of bipolar disorder who reports taking a handful of medications, what information is most important to obtain?

Correct answer: A

Rationale: The correct answer is to obtain information on what drugs the client used in the suicide attempt. This information is crucial for assessing the severity of the overdose, potential drug interactions, and determining the appropriate treatment plan. Choice B is not as urgent as identifying the drugs taken during the suicide attempt. Choice C, while important, is not as immediately critical as knowing the specific medications involved. Choice D is unrelated to the immediate medical needs of the client.

4. A client with cirrhosis is admitted with jaundice, fatigue, and a distended abdomen. Which laboratory result is most important for the nurse to monitor?

Correct answer: A

Rationale: Corrected Rationale: In clients with cirrhosis, elevated ammonia levels can lead to hepatic encephalopathy, which is a serious complication. Monitoring ammonia levels is crucial to assess for changes in mental status and initiate treatment if needed. White blood cell count (choice B) is not the most important parameter to monitor in this scenario as it does not directly relate to the complications of cirrhosis. Albumin level (choice C) and hemoglobin level (choice D) are also important in cirrhosis, but in this case, monitoring ammonia level takes precedence due to its direct association with hepatic encephalopathy.

5. A client with a history of hypertension and hyperlipidemia is admitted with chest pain. What is the nurse's priority action?

Correct answer: B

Rationale: The correct answer is to obtain a 12-lead electrocardiogram (ECG). This action is crucial in assessing the heart's electrical activity and helps in the evaluation of chest pain. Administering nitroglycerin (Choice A) may be necessary but should come after obtaining the ECG to confirm the diagnosis. Checking vital signs (Choice C) is important but does not provide direct information about the heart's electrical status. Placing the client on continuous telemetry (Choice D) may be appropriate later but does not provide immediate information on the heart's electrical activity as an ECG does.

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