The nurse is admitting a 69-year-old male patient with acute heart failure. The physician has ordered furosemide 80 mg IV stat, digoxin 0.25 mg PO, and potassium chloride 20 mEq PO now. Which assessment finding is most indicative of an ineffective response 2 hours after the administration of all the medications?

Pulse oximetry 96%.

Heart rate of 77, regular.

Trace bilateral ankle edema.

Urine output 60 mL.

Answer and Explanation

The Correct Answer is D

The correct answer is d. Urine output 60 mL.

Choice A reason: A pulse oximetry reading of 96% is within normal limits and does not indicate an ineffective response to the medications.

Choice B reason: A heart rate of 77, regular, is also within normal limits and does not suggest an ineffective response.

Choice C reason: Trace bilateral ankle edema may persist even after effective treatment due to residual effects of heart failure.

Choice D reason: A urine output of 60 mL over 2 hours post-diuretic administration suggests an inadequate response, as furosemide is expected to produce a significant diuresis to reduce fluid overload in acute heart failure.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A reason: The statement about being able to sit down to put on pants and shoes indicates that the client is implementing safety measures to prevent falls, which is a positive outcome of effective teaching.

Choice B reason: Exercising daily and resting when tired is an appropriate strategy for managing Parkinson's disease symptoms, suggesting that the client has understood the education provided.

Choice C reason: The statement about not needing a walker could indicate a lack of understanding of the importance of mobility aids in preventing falls, which is a concern for clients with Parkinson's disease.

Choice D reason: Removing loose rugs from the house is a preventive measure to reduce fall risk, indicating that the client and family have understood and applied the education.

A. A 50-year-old woman who had a thyroidectomy. B. A 49-year-old man who works in a pesticide factory. C. A 25-year-old woman with thyroid nodules. D. A 71-year-old man with vomiting secondary to influenza.

Correct Answer is A

Explanation

Choice A reason: A thyroidectomy, which is the surgical removal of the thyroid gland, directly leads to hypothyroidism because the body can no longer produce thyroid hormones. This client is at the greatest risk of developing hypothyroidism.

Choice B reason: While exposure to certain chemicals in pesticides can be a risk factor for thyroid dysfunction, it does not pose as immediate a risk as the removal of the thyroid gland itself.

Choice C reason: Thyroid nodules can be associated with thyroid dysfunction, but not all nodules result in hypothyroidism, and many are benign and asymptomatic.

Choice D reason: Vomiting secondary to influenza is not directly related to the development of hypothyroidism.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing education to the client with Parkinson's disease and their family. The nurse understands that teaching has not been effective when the client makes which of the following statements?

Correct Answer is C

Explanation

The nurse practitioner is assessing clients for their risk of developing hypothyroidism. Which of these clients would the nurse consider at greatest risk?

Correct Answer is A

Explanation

The nurse is reviewing data of a client receiving propylthiouracil (PTU). Which information indicates to the nurse that the client may be experiencing a side effect of this medication?

Assessment of a client with cirrhosis reveals a distended abdomen, weight gain, and dyspnea. Based on this information, what interventions would the nurse include in this client's plan of care?

The nurse caring for a client with thyroid disease notes a current T4 level of 2.9 mcg/dL (normal range: 5-11.5 mcg/dL). Which findings are consistent with this result?

The nurse is admitting a client diagnosed with a urinary tract infection (UTI) and sepsis. Which intervention would the nurse consider a priority?

The nurse is reviewing arterial blood gas (ABG) results for a client with diabetic ketoacidosis. Which result is consistent with this diagnosis?

A client with thyroid disease is being treated with propylthiouracil (PTU). Which statement made by the client indicates the medication therapy is effective?