Nokea
The nurse is teaching a client with a new diagnosis of type 2 diabetes about metformin (Glucophage). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication with meals.
- B. I should report nausea to my doctor.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping metformin when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: taking with meals reduces GI upset, nausea is a side effect, and alcohol increases lactic acidosis risk.
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The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistants. The RN should care for which of the following patients?
- A. A patient with a chest tube who is ambulating in the hall.
- B. A patient with a colostomy who requires assistance with an irrigation.
- C. A patient with a right-sided cerebral vascular accident (CVA) who requires assistance with bathing.
- D. A patient who is refusing medication to treat cancer of the colon.
Correct Answer: D
Rationale: requires assessment skills of the RN
The nurse is teaching a community group about how to prevent Lyme disease. What should be included in the teaching? Select all that apply.
- A. Wear dark-colored clothing when outdoors.
- B. Tuck long pants inside socks.
- C. Wear long sleeves and long pants when outside.
- D. Remove standing water.
- E. Use insect repellant containing DEET.
- F. Do not eat venison.
Correct Answer: B,C,E
Rationale: Tucking pants into socks, wearing long clothing, and using DEET repel ticks, preventing Lyme disease. Light clothing aids tick visibility, standing water is irrelevant, and venison is safe.
A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse 'What is our major concern now, and what will we have to deal with in the future?' Which of the following is the best response?
- A. There is a probability of life-long complications.
- B. Cystic fibrosis results in nutritional concerns that can be dealt with.
- C. Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis.
- D. You will work with a team of experts and also have access to a support group that the family can attend.
Correct Answer: C
Rationale: Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis. Respiratory issues are the primary concern due to chronic lung complications.
The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by which of the following observations?
- A. The child is able to state his name when asked who he is.
- B. The child reaches for a stuffed animal brought from home.
- C. The child maintains himself in opisthotonos.
- D. The child withdraws from mildly painful stimuli.
Correct Answer: A
Rationale: Stating his name indicates orientation, a positive sign post-head injury. Options B, C, and D are less reassuring: reaching for a toy is nonspecific, opisthotonos suggests meningeal irritation, and withdrawal may occur in unconscious states.
In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?
- A. Increased 10% in height
- B. 2 deciduous teeth
- C. Tripled the birth weight
- D. Head > chest circumference
Correct Answer: C
Rationale: Tripled the birth weight. Infants typically triple their birth weight by 12 months.