Nokea
The nurse is caring for a client with a history of type 2 diabetes who is receiving metformin (Glucophage) 500 mg PO bid. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Creatinine 2.0 mg/dL.
- B. Hemoglobin A1c 7.0%.
- C. Potassium 4.0 mEq/L.
- D. Fasting glucose 120 mg/dL.
Correct Answer: A
Rationale: A creatinine of 2.0 mg/dL indicates renal impairment, increasing the risk of lactic acidosis with metformin, requiring immediate evaluation. Options B, C, and D are less concerning: A1c 7.0% shows fair control, potassium 4.0 mEq/L is normal, and glucose 120 mg/dL is acceptable.
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An adult who has a hiatal hernia is seen in clinic. The nurse is reviewing her care with her. Which comment by the client indicates a need for more teaching about managing her condition?
- A. I sit up for an hour after eating.
- B. I miss drinking soda, but I know it is not good for me.
- C. I like to go swimming every day.
- D. I drink hot chocolate instead of coffee.
Correct Answer: D
Rationale: Hot chocolate contains caffeine, which can relax the lower esophageal sphincter, worsening hiatal hernia symptoms. Sitting up, avoiding soda, and swimming are appropriate for management.
A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
- A. Request a private evaluation of the female's scalp from her parents.
- B. Contact the female's parents about the observations.
- C. Observe the hairline and scalp for possible signs of lice.
- D. Contact the student's physician.
Correct Answer: C
Rationale: Observation of the student's hair is the next step.
A postoperative client has pain medication ordered PRN for discomfort. During the first assessment, the nurse notes that the client has not received pain medication all day. His vital signs are within normal limits, but he is sweating profusely. He smiles at you while speaking and states that he is not hot but is still experiencing some pain and has been since early this morning. What is the most appropriate nursing action?
- A. Administer the largest dose of pain medication allowed because he has been without it all day and then allow him to rest undisturbed.
- B. Administer the minimum dose of medication and reassess his level of pain 30 minutes after administration.
- C. Hold the pain medication because his vital signs are within normal limits and he is smiling and showing no evidence of being in pain.
- D. Encourage the client to continue to do without pain medication so he won't become addicted to the opioid.
Correct Answer: B
Rationale: Administering the minimum dose and reassessing ensures effective pain management while monitoring response, given diaphoresis and reported pain.
A patient with a cuffed tracheostomy tube in place after surgery.
The nurse knows the purpose of the cuff on the tracheostomy tube is to
- A. guarantee secure placement of the tracheostomy tube in the airway.
- B. prevent ischemia of the tracheal wall by distributing the pressure applied to it.
- C. decrease the chance of aspiration into the trachea.
- D. protect the trachea from ischemia and edema.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate, not the purpose of the cuff on a tracheostomy tube (2) complication of using a cuffed tracheostomy tube (3) correct-seals trachea, helps to prevent aspiration (4) trauma from overinflated tube may cause edema
A two-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse.
An appropriate nursing diagnosis is high risk for
- A. impaired swallowing.
- B. failure to thrive.
- C. fluid volume deficit.
- D. altered health maintenance.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) no information about swallowing provided with question (2) this is a medical diagnosis not a nursing diagnosis (3) correct-may become dehydrated (4) not specific for problem described