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 client statements would be of GREATest concern to the nurse?
- A. I have a headache sometimes.
- B. I feel tired in the afternoon.
- C. I have pain in my upper abdomen.
- D. I take my medication with breakfast.
Correct Answer: C
Rationale: Upper abdominal pain may indicate pancreatitis, a rare but serious side effect of sitagliptin, requiring immediate evaluation. Options A, B, and D are less concerning: headaches and fatigue are nonspecific, and taking with breakfast is acceptable.
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The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?
- A. Send the staff member home.
- B. Assess the staff member's compliance with standard precautions.
- C. Assign the staff member only to clients with chronic diseases.
- D. Re-assign the staff member to clean the supply closet.
Correct Answer: A
Rationale: extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis, highly contagious; infected employees cannot work until symptoms have resolved in 3-7 days
The nurse is caring for a patient following surgery for a coronary artery bypass graft (CABG). Which of the following symptoms would the nurse expect to see if the patient was in the early stages of circulatory overload?
- A. Change in the character of respirations.
- B. Fluctuation in the blood pressure.
- C. Reduction in tissue turgor.
- D. Increase in body temperature.
Correct Answer: A
Rationale: will see dyspnea, cough, edema, hemoptysis
In caring for an elderly client with a depressed affect, which of the following nursing actions would be MOST appropriate to help the client to complete activities of daily living?
- A. Medicate the client before the activities begin.
- B. Develop a written schedule of activities, allowing extra time.
- C. Assist the client with grooming activities so it doesn't take as long.
- D. Provide frequent forceful direction to keep the client focused.
Correct Answer: B
Rationale: written schedule with built-in extra time will allow client to understand what is expected and will allow him to participate at a slower pace
Twenty-four hours after abdominal surgery.
Which of the following plans would be a nursing priority to prevent complications of flatulence?
- A. Encourage the client to drink carbonated beverages daily.
- B. Instruct the client to turn from side to side.
- C. Encourage the client to do leg exercises in bed.
- D. Assist the client to walk in the hall every 2 hours.
Correct Answer: D
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) increasing carbonated beverages will increase flatus (2) will prevent postoperative complications, but not flatulence (3) does not address flatulence (4) correct-will increase peristalsis, decreasing the development of flatus
The nurse is preparing to administer insulin to a client with type I diabetes.
- A. Which action should the nurse take first before administering insulin to a client with type I diabetes?
- B. Verify the insulin dose with another nurse.
- C. Check the client’s blood glucose level.
- D. Cleanse the injection site with alcohol.
- E. Rotate the injection site from the previous dose.
Correct Answer: B
Rationale: Checking the client’s blood glucose level is the first step to ensure the insulin dose is appropriate, preventing hypo- or hyperglycemia. Verifying the dose, cleansing the site, and rotating sites are important but follow glucose confirmation.