,1.
A nurse is caring for a client who was newly diagnosed with hypothyroidism and
began taking levothyroxine (Synthroid) 0.25 mg orally once daily six weeks ago.
During a follow-up appointment, the provider reviews the client's laboratory results
to determine whether the medication has achieved the desired therapeutic effect.
Which assessment finding best indicates that levothyroxine therapy has been
effective?
Correct Answer: THYROID-STIMULATING HORMONE (TSH) LEVEL OF 2
MICROUNITS/ML
Rationale: A TSH level of approximately 2 microunits/mL falls within the normal
therapeutic range, indicating that thyroid hormone replacement is adequately
suppressing excess TSH secretion from the pituitary gland. Levothyroxine therapy is
primarily monitored using serum TSH levels because they reflect the body's response
to thyroid hormone replacement. A normalized TSH demonstrates appropriate dosing
and effective management of hypothyroidism.
2.
A nurse is providing discharge teaching to a client who has recently been prescribed
prazosin (Minipress) for hypertension. The nurse evaluates the client's understanding
of medication safety before discharge. Which client statement demonstrates correct
understanding of the teaching?
Correct Answer: "I WILL MOVE SLOWLY FROM SITTING TO STANDING TO PREVENT
FALLS."
Rationale: Prazosin commonly causes first-dose orthostatic hypotension by dilating
blood vessels and lowering blood pressure. Rising slowly allows the cardiovascular
system time to adjust, reducing dizziness, syncope, and fall risk. Teaching clients
about positional changes is an important intervention to prevent injury during
therapy.
,3.
A nurse is teaching a client who has recently started taking phenytoin (Dilantin) for
seizure management. During the education session, the client makes several
statements regarding the medication. Which statement indicates that the client
requires additional teaching?
Correct Answer: "I SHOULD EXPECT A RASH TO DEVELOP."
Rationale: A rash is not an expected adverse effect of phenytoin and may indicate
a serious hypersensitivity reaction such as Stevens-Johnson syndrome or toxic
epidermal necrolysis. Clients should immediately notify their healthcare provider if
any rash develops because prompt discontinuation of the medication may be
necessary to prevent life-threatening complications.
4.
A nurse receives a telephone prescription from a healthcare provider for an antibiotic
to treat a hospitalized client's infection. To ensure medication safety and comply with
professional standards, what action is the nurse required to perform after
documenting the prescription?
Correct Answer: READ THE PRESCRIPTION BACK TO THE PROVIDER AFTER
TRANSCRIBING
Rationale: Reading the prescription back verifies accuracy and reduces the risk of
medication errors caused by miscommunication or misunderstanding during
telephone orders. This closed-loop communication process is required by patient
safety standards and helps ensure that the prescribed medication, dosage, route, and
frequency are correctly documented.
5.
A nurse is teaching an adolescent client and family following a new diagnosis of a
seizure disorder. The client has been prescribed phenytoin (Dilantin) for long-term
, seizure control. Which statement by the client indicates that the teaching has been
effective?
Correct Answer: "I WILL KEEP A SEIZURE FREQUENCY CHART."
Rationale: Maintaining a seizure diary helps monitor treatment effectiveness,
identify seizure triggers, and provide valuable information for medication
adjustments during follow-up appointments. Accurate documentation assists the
healthcare provider in evaluating therapeutic response and determining whether
additional interventions are necessary.
6.
A nurse is caring for a client with heart failure who is receiving furosemide (Lasix)
and digoxin (Lanoxin). Morning laboratory results reveal a potassium level of 2.6
mEq/L. Which nursing intervention should the nurse perform first?
Correct Answer: APPLY A CARDIAC MONITOR
Rationale: Severe hypokalemia significantly increases the risk of life-threatening
dysrhythmias, especially in clients receiving digoxin because low potassium enhances
digoxin toxicity. Continuous cardiac monitoring allows immediate detection of
dangerous rhythm disturbances while additional interventions, such as potassium
replacement, are initiated.
7.
A nurse administers ceftazidime (Fortaz) to a client with a documented severe allergy
to penicillin. Shortly after administration, the client develops respiratory symptoms.
Which finding requires the nurse to complete an incident report?
Correct Answer: THE CLIENT REPORTS SHORTNESS OF BREATH
Rationale: Shortness of breath following administration of a cephalosporin in a
client with a severe penicillin allergy may indicate an anaphylactic reaction requiring
immediate intervention. An incident report is completed because this represents an
A nurse is caring for a client who was newly diagnosed with hypothyroidism and
began taking levothyroxine (Synthroid) 0.25 mg orally once daily six weeks ago.
During a follow-up appointment, the provider reviews the client's laboratory results
to determine whether the medication has achieved the desired therapeutic effect.
Which assessment finding best indicates that levothyroxine therapy has been
effective?
Correct Answer: THYROID-STIMULATING HORMONE (TSH) LEVEL OF 2
MICROUNITS/ML
Rationale: A TSH level of approximately 2 microunits/mL falls within the normal
therapeutic range, indicating that thyroid hormone replacement is adequately
suppressing excess TSH secretion from the pituitary gland. Levothyroxine therapy is
primarily monitored using serum TSH levels because they reflect the body's response
to thyroid hormone replacement. A normalized TSH demonstrates appropriate dosing
and effective management of hypothyroidism.
2.
A nurse is providing discharge teaching to a client who has recently been prescribed
prazosin (Minipress) for hypertension. The nurse evaluates the client's understanding
of medication safety before discharge. Which client statement demonstrates correct
understanding of the teaching?
Correct Answer: "I WILL MOVE SLOWLY FROM SITTING TO STANDING TO PREVENT
FALLS."
Rationale: Prazosin commonly causes first-dose orthostatic hypotension by dilating
blood vessels and lowering blood pressure. Rising slowly allows the cardiovascular
system time to adjust, reducing dizziness, syncope, and fall risk. Teaching clients
about positional changes is an important intervention to prevent injury during
therapy.
,3.
A nurse is teaching a client who has recently started taking phenytoin (Dilantin) for
seizure management. During the education session, the client makes several
statements regarding the medication. Which statement indicates that the client
requires additional teaching?
Correct Answer: "I SHOULD EXPECT A RASH TO DEVELOP."
Rationale: A rash is not an expected adverse effect of phenytoin and may indicate
a serious hypersensitivity reaction such as Stevens-Johnson syndrome or toxic
epidermal necrolysis. Clients should immediately notify their healthcare provider if
any rash develops because prompt discontinuation of the medication may be
necessary to prevent life-threatening complications.
4.
A nurse receives a telephone prescription from a healthcare provider for an antibiotic
to treat a hospitalized client's infection. To ensure medication safety and comply with
professional standards, what action is the nurse required to perform after
documenting the prescription?
Correct Answer: READ THE PRESCRIPTION BACK TO THE PROVIDER AFTER
TRANSCRIBING
Rationale: Reading the prescription back verifies accuracy and reduces the risk of
medication errors caused by miscommunication or misunderstanding during
telephone orders. This closed-loop communication process is required by patient
safety standards and helps ensure that the prescribed medication, dosage, route, and
frequency are correctly documented.
5.
A nurse is teaching an adolescent client and family following a new diagnosis of a
seizure disorder. The client has been prescribed phenytoin (Dilantin) for long-term
, seizure control. Which statement by the client indicates that the teaching has been
effective?
Correct Answer: "I WILL KEEP A SEIZURE FREQUENCY CHART."
Rationale: Maintaining a seizure diary helps monitor treatment effectiveness,
identify seizure triggers, and provide valuable information for medication
adjustments during follow-up appointments. Accurate documentation assists the
healthcare provider in evaluating therapeutic response and determining whether
additional interventions are necessary.
6.
A nurse is caring for a client with heart failure who is receiving furosemide (Lasix)
and digoxin (Lanoxin). Morning laboratory results reveal a potassium level of 2.6
mEq/L. Which nursing intervention should the nurse perform first?
Correct Answer: APPLY A CARDIAC MONITOR
Rationale: Severe hypokalemia significantly increases the risk of life-threatening
dysrhythmias, especially in clients receiving digoxin because low potassium enhances
digoxin toxicity. Continuous cardiac monitoring allows immediate detection of
dangerous rhythm disturbances while additional interventions, such as potassium
replacement, are initiated.
7.
A nurse administers ceftazidime (Fortaz) to a client with a documented severe allergy
to penicillin. Shortly after administration, the client develops respiratory symptoms.
Which finding requires the nurse to complete an incident report?
Correct Answer: THE CLIENT REPORTS SHORTNESS OF BREATH
Rationale: Shortness of breath following administration of a cephalosporin in a
client with a severe penicillin allergy may indicate an anaphylactic reaction requiring
immediate intervention. An incident report is completed because this represents an
