Nokea
The nurse is caring for a client with a history of type 2 diabetes who is receiving glipizide (Glucotrol) 5 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Sweating and shakiness.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a serious glipizide side effect. Options A, C, and D are less urgent.
You may also like to solve these questions
A 22-year-old mother of a 4-year-old boy comes to the antepartal clinic. Her second pregnancy has just been confirmed.
During this initial visit, it MOST important for the nurse to
- A. assess the client's feelings about pregnancy, labor, and delivery.
- B. obtain a history of the client's last labor and delivery.
- C. determine how the client's 4-year-old feels about the pregnancy.
- D. identify the client's general health needs.
Correct Answer: D
Rationale: Strategy: Think about each answer choice. (1) important data, priority is the here and now (2) important data, but not priority for first visit (3) important data, need to deal with the mother's needs first (4) correct-optimal opportunity for preventative health maintenance
The nurse is caring for a client after an ileostomy. The nurse would be MOST concerned if which of the following was observed?
- A. The ileostomy functions without daily irrigations.
- B. The stoma appears to be tight, and there is a decreased amount of stool.
- C. A small amount of mucus is seen around the anal area.
- D. There is weight gain of 5 lb over a three-week period of time.
Correct Answer: B
Rationale: important to report these findings to the physician; may indicate an obstruction or stoma stricture
A 12-year-old boy injured his right knee yesterday during a soccer game.
- A. Which medication is best for a 12-year-old boy with a painful, swollen knee and hemophilia A?
- B. Oxycodone terephthalate (Percodan).
- C. Ibuprofen (Motrin).
- D. Enteric-coated aspirin.
- E. Codeine phosphate (Paveral).
Correct Answer: D
Rationale: Codeine is an appropriate analgesic for moderate to severe pain in hemophilia A, as it does not increase bleeding risk. Oxycodone (contains aspirin), ibuprofen, and aspirin prolong bleeding time and are contraindicated in bleeding disorders.
A four-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by his mother. Which of the following statements would the nurse expect the mother to make about her son's symptoms?
- A. My son's bowel movements have turned black and sticky.
- B. I really have to encourage my son to suck the bottle.
- C. My son is fussy and seems hungry all the time.
- D. My son spits up green liquid after feeding.
Correct Answer: C
Rationale: becomes lethargic, dehydrated, and malnourished
An elderly man is admitted to an inpatient psychiatric unit with an initial diagnosis of psychotic depression. The INITIAL nursing priority is to
- A. clarify perceptual distortions.
- B. establish reality orientation.
- C. ensure client and milieu safety.
- D. increase self-esteem.
Correct Answer: C
Rationale: initial nursing priority for all psychiatric patients is to ensure their safety and the safety of all members of the milieu