Nursing Elites

1. A nurse is reviewing the medication metformin with a client who has diabetes. Which of the following side effects should the nurse discuss?

• A. Gastrointestinal upset
• B. Increased appetite
• C. Weight loss
• D. Frequent urination

Correct answer: A

Rationale: The correct answer is A: Gastrointestinal upset. Metformin can cause gastrointestinal upset, especially when first starting therapy. It is important to take it with food to reduce these effects. Increased appetite (choice B) and weight loss (choice C) are not common side effects of metformin but may occur due to improved blood sugar control. Frequent urination (choice D) is a symptom of uncontrolled diabetes and not a side effect of metformin.

2. A nurse is assessing a client with chronic kidney disease. Which of the following findings should the nurse monitor?

• A. Hypokalemia
• B. Fluid overload
• C. Decreased blood pressure
• D. Increased appetite

Correct answer: B

Rationale: The correct answer is B: Fluid overload. Clients with chronic kidney disease are prone to fluid overload due to impaired kidney function. The kidneys may not effectively regulate fluid balance, leading to fluid retention. Monitoring for signs of fluid overload, such as edema, hypertension, and shortness of breath, is crucial. Choice A, Hypokalemia, is less likely in chronic kidney disease as the kidneys often have difficulty excreting potassium, leading to hyperkalemia. Decreased blood pressure (Choice C) is not a common finding in chronic kidney disease unless complications like volume depletion occur. Increased appetite (Choice D) is not typically associated with chronic kidney disease; in fact, many clients may experience a decreased appetite due to various factors such as uremia and dietary restrictions.

3. A nurse is assessing a client with pericarditis. Which of the following findings is the priority for the nurse to report?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: A paradoxical pulse is a sign of cardiac tamponade, a life-threatening complication of pericarditis that requires immediate intervention. It results from decreased cardiac output due to increased pressure in the pericardial sac. Reporting this finding promptly allows for timely treatment to prevent further deterioration. Dependent edema and substernal chest pain are common in pericarditis but are not as urgent as a paradoxical pulse. A pericardial friction rub is a classic finding in pericarditis and indicates inflammation but is not as critical as a paradoxical pulse.

4. A nurse is reviewing discharge instructions with the parents of a newborn. Which of the following statements indicates a need for further teaching?

• A. We will place the baby on its back to sleep
• B. We will give the baby a pacifier at bedtime
• C. We will keep the baby's crib free of blankets and toys
• D. We will leave the baby's diaper off to prevent diaper rash

Correct answer: D

Rationale: The correct answer is D. Leaving the baby's diaper off to prevent diaper rash is not recommended because it increases the risk of infection. Proper diaper hygiene and frequent diaper changes are more effective in preventing diaper rash. Choices A, B, and C are correct as placing the baby on its back to sleep, giving the baby a pacifier at bedtime, and keeping the baby's crib free of blankets and toys are appropriate measures to ensure the newborn's safety and reduce the risk of Sudden Infant Death Syndrome (SIDS).

5. A client is receiving ferrous sulfate. Which of the following should be monitored?

• A. Serum potassium levels
• B. Hemoglobin levels
• C. Liver function tests
• D. Blood glucose levels

Correct answer: B

Rationale: The correct answer is B: Hemoglobin levels. Ferrous sulfate is used to treat iron deficiency anemia by increasing the body's iron stores. Monitoring hemoglobin levels is crucial as it reflects the effectiveness of the treatment in improving the client's anemia. Serum potassium levels (Choice A) are typically not directly affected by ferrous sulfate. Liver function tests (Choice C) and blood glucose levels (Choice D) are not routinely monitored when a client is receiving ferrous sulfate unless there are specific indications or pre-existing conditions that warrant such monitoring.

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