Nokea
The nurse is caring for a client with a history of type 2 diabetes who is receiving sitagliptin (Januvia) 100 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Upper abdominal pain.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Upper abdominal pain may indicate pancreatitis, a serious sitagliptin side effect. Options A, C, and D are less urgent.
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The nurse evaluates the nutritional intake of a 16-year-old girl at a camp for adolescents. The girl eats all of the food provided to her at the camp cafeteria. Each of the day's three meals contains foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating monthly for about two years. Which of the following descriptions, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height?
- A. Her diet is low in calories and high in iron.
- B. Her diet is low in calories and low in iron.
- C. Her diet is high in calories and low in iron.
- D. Her diet is high in calories and high in iron.
Correct Answer: C
Rationale: 900 × 3 = 2,700 calories/day and women need 1,200-1,500 kcal/day (men need 1,500-1,800 kcal/day); 3 mg × 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required
The nurse is administering digoxin to a 6-month-old infant. Which finding would cause the nurse to withhold the medication and notify the charge nurse or the physician?
- A. Apical heart rate of 85
- B. Appears lethargic
- C. Circumoral cyanosis
- D. Respiratory rate of 38
Correct Answer: A
Rationale: An apical heart rate below 100 in infants indicates bradycardia, a contraindication for digoxin due to toxicity risk, requiring withholding and reporting.
The nurse is caring for a client who is postoperative day 1 after a cesarean section. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Lochia rubra with small clots.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, such as endometritis, a serious complication post-cesarean section requiring immediate evaluation. Options B, C, and D are expected: incision pain, lochia rubra, and urine output 50 mL/hour are normal on day 1.
The nurse is teaching a client with a new diagnosis of hypertension about lisinopril (Prinivil). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report a persistent dry cough.
- C. Stop the medication if blood pressure is normal.
- D. Avoid regular blood pressure checks.
Correct Answer: B
Rationale: A persistent dry cough is a common lisinopril side effect, requiring reporting. Options A, C, and D are incorrect.
A prenatal client tests positive for chlamydia in her ninth month. She asks why she should be treated since she does not have symptoms. The nurse should tell the client that if she is not treated before delivery, there is a risk of which problem?
- A. Transplacental infection of the fetus
- B. Neonatal ophthalmia
- C. Pregnancy-induced hypertension
- D. Congenital anomalies
Correct Answer: B
Rationale: Untreated chlamydia can cause neonatal conjunctivitis (ophthalmia neonatorum) during vaginal delivery, necessitating treatment to prevent infant complications.