Nokea
A client with a history of type 2 diabetes mellitus is prescribed metformin (Glucophage). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild nausea.
- B. Metallic taste.
- C. Lactic acidosis symptoms.
- D. Weight gain.
Correct Answer: C
Rationale: Lactic acidosis is a rare but serious side effect of metformin, requiring immediate reporting of symptoms like muscle pain or weakness.
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What is the primary goal of nursing care during the emergent phase after a burn injury?
- A. Replace lost fluids.
- B. Prevent infection.
- C. Control pain.
- D. Promote wound healing.
Correct Answer: A
Rationale: Replacing lost fluids is the primary goal in the emergent phase to prevent hypovolemic shock due to fluid loss from burns.
The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments?
- A. Interstitial compartment.
- B. Intravascular compartment.
- C. Extracellular compartment.
- D. Intracellular compartment.
Correct Answer: C
Rationale: These symptoms indicate fluid excess in the extracellular compartment, which includes interstitial spaces (edema) and intravascular spaces (contributing to lung crackles).
The client has sore nares while a nasogastric (NG) tube is in place. Which of the following nursing measures would be most appropriate to help alleviate the client's discomfort?
- A. Reposition the tube in the nares.
- B. Irrigate the tube with a cool solution.
- C. Apply a water-soluble lubricant to the nares.
- D. Have the client change position more frequently.
Correct Answer: C
Rationale: Applying a water-soluble lubricant to the nares reduces irritation and discomfort caused by the NG tube.
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says:
- A. If I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: D
Rationale: Clients with preterm labor should get out of the car every 1-2 hours to promote circulation and prevent complications, not every 4 hours, indicating a need for further instruction.
A client with a history of breast cancer is prescribed letrozole (Femara). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Letrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.