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The nurse is teaching a client with a new diagnosis of type 2 diabetes about metformin (Glucophage). Which of the following instructions should the nurse include?
- A. Take the medication on an empty stomach.
- B. Report any nausea or diarrhea.
- C. Stop the medication if blood sugar is normal.
- D. Avoid regular kidney function Test s.
Correct Answer: B
Rationale: Nausea or diarrhea are common metformin side effects that may require dose adjustment, so reporting is important. Options A, C, and D are incorrect.
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The nurse is providing home care to a postoperative client who has a wound infection. What is essential to include when teaching the family about infection transmission?
- A. The client should stay isolated from the rest of the family.
- B. No one who is pregnant should care for the client.
- C. The family should wash hands before and after caring for the client.
- D. The client should not be allowed to have any visitors.
Correct Answer: C
Rationale: Hand washing before and after care is critical to prevent infection transmission. Isolation, restricting pregnant caregivers, or banning visitors are not necessary unless specified.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD).
- A. Which intervention should the nurse include in the care plan for a client with COPD?
- B. Encourage a high-protein, low-carbohydrate diet.
- C. Administer oxygen at 6 liters per minute via nasal cannula.
- D. Teach the client to use pursed-lip breathing.
- E. Place the client in a supine position to promote rest.
Correct Answer: C
Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and improving oxygenation in COPD. High-protein diets are beneficial but secondary, high-flow oxygen risks CO2 retention, and supine positioning impairs breathing.
The nurse and a nursing assistant are preparing to move an elderly immobile client up in the bed using a sheet. The staff should be standing on opposite sides of the bed even with the client's:
- A. Hips
- B. Knees
- C. Shoulders
- D. Chest
Correct Answer: C
Rationale: Positioning at the shoulders aligns staff with the client's upper body, ensuring safe and effective movement.
The nurse is planning discharge for a client who suffered a mild myocardial infarction (MI) and smokes one pack of cigarettes per day.
Which of the following recommendations by the nurse would be BEST?
- A. Participation in a program such as 'Nicotine Avoidance.'
- B. Avoidance of aerobic physical activity.
- C. Instillation of a humidifier in the home heating system.
- D. Strict adherence to a low-calorie, low-sodium, high-lipid diet.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-smoking is definitely a modifiable risk factor, self-help program can significantly aid in quitting (2) well-planned aerobic physical activity program is a must (3) humidification does not modify the risk factors (4) low-calorie is appropriate, needs a low-fat, not a high-fat, diet
The nurse is teaching a client who has short-term memory loss how to use the call light. Which factor is least essential for the nurse to assess when teaching this client?
- A. Visual status
- B. Ambulatory difficulty
- C. Orientation to time, place, and person
- D. Understanding of the English language
Correct Answer: B
Rationale: Ambulatory difficulty is least relevant, as call light use relies on vision, orientation, and language comprehension, not mobility.