Nokea
The nurse is caring for a client with a history of type 2 diabetes who is receiving exenatide (Byetta) 10 mcg SC bid. Which of the following symptoms should the nurse report immediately?
- A. Mild nausea
- B. Upper abdominal pain
- C. Occasional thirst
- D. Mild fatigue
Correct Answer: B
Rationale: Upper abdominal pain may indicate pancreatitis, a serious exenatide side effect. Options A, C, and D are less urgent: nausea is common, thirst is expected, and fatigue is nonspecific.
You may also like to solve these questions
The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child?
- A. Using a moist soft brush or cloth to clean teeth and gums
- B. Swabbing teeth and gums with flavored mouthwash
- C. Offering a bottle of water for the child to drink
- D. Brushing with toothpaste and flossing each tooth
Correct Answer: A
Rationale: Using a moist soft brush or cloth to clean teeth and gums. The nurse should use a soft cloth or soft brush to do mouth care so that the child can adjust to the routine of cleaning the mouth and teeth.
The nurse is caring for a client with a history of rheumatoid arthritis who is receiving prednisone 10 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 gained 5 pounds this month.
- D. I take my medication with food.
Correct Answer: C
Rationale: Weight gain of 5 pounds in a month suggests a side effect of prednisone, such as fluid retention or increased appetite, requiring evaluation to prevent complications like hypertension. Options A, B, and D are less concerning: headaches and fatigue are nonspecific, and taking with food is appropriate.
The nurse is caring for a client who is postoperative day 1 after a mitral valve replacement. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Heart rate of 90 bpm.
- C. Chest tube drainage of 100 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-valve replacement due to risk of endocarditis, requiring immediate evaluation. Options B, C, and D are expected or normal: heart rate 90 bpm, drainage 100 mL/hour, and blood pressure 130/80 mmHg are stable.
A 33-year-old woman comes to the local outpatient clinic for complaints of dizziness and palpitations. Her physical exam and laboratory results are normal. She reports that the company she owns is on the verge of bankruptcy.
Which of the following responses, if made to the client by the nurse, would be BEST?
- A. When did you first notice these symptoms?'
- B. Have you shared this information with anyone?'
- C. Are you concerned about your financial difficulties?'
- D. Would you like to discuss your situation with me?'
Correct Answer: A
Rationale: Strategy: 'BEST' indicates there may be more than one correct response. Remember therapeutic communication. (1) correct-open-ended question, encourages client to discuss when problems occurred (2) yes/no question, nontherapeutic, doesn't encourage discussion of symptoms (3) yes/no question, nontherapeutic, too confrontational, does not encourage discussion (4) yes/no question, nontherapeutic
A client is receiving a nitroglycerin infusion for unstable angina. What assessment would be a priority when monitoring the effects of this medication?
- A. Blood pressure
- B. Cardiac enzymes
- C. ECG analysis
- D. Respiratory rate
Correct Answer: A
Rationale: Since an effect of this drug is vasodilation, the client must be monitored for hypotension.