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 healthcare professional is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare professional use?

• A. Numeric rating scale
• B. Behavioral indicators
• C. Visual analog scale
• D. Faces pain scale

Correct answer: B

Rationale: For clients with dementia who have difficulty communicating, assessing pain using behavioral indicators like increased agitation and restlessness is more effective than relying on self-reported scales such as numeric rating scale, visual analog scale, or faces pain scale. Behavioral indicators provide valuable insights into pain perception in individuals who may have challenges expressing themselves verbally.

3. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

• A. Place the client in seclusion when she is confused
• B. Request a prescription for PRN restraints when the client is wandering
• C. Dim the lighting in the client’s room
• D. Leave one side rail up on the client's bed

Correct answer: D

Rationale: The correct answer is to leave one side rail up on the client's bed. This action can help prevent falls while allowing the client to get up safely when needed, reducing the risk of injury from wandering. Placing the client in seclusion (Choice A) is not appropriate as it can lead to increased agitation and distress. Requesting restraints (Choice B) should be avoided as it can increase the risk of injuries and is not recommended for clients with Alzheimer's. Dimming the lighting (Choice C) may increase confusion and disorientation in clients with Alzheimer's disease.

4. A healthcare professional is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output?

• A. Shivering
• B. Oliguria
• C. Bradypnea
• D. Constricted pupils

Correct answer: B

Rationale: Oliguria (low urine output) is a sign of decreased cardiac output because the kidneys are not being adequately perfused, leading to reduced urine production. Shivering (choice A) is a response to hypothermia, not directly related to cardiac output. Bradypnea (choice C) refers to abnormally slow breathing rate and is not a direct indicator of decreased cardiac output. Constricted pupils (choice D) can be caused by medications or sympathetic nervous system stimulation but are not specific to decreased cardiac output.

5. A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?

• A. Contact provider if the cord turns black
• B. Clean the base of the cord with hydrogen peroxide daily
• C. Keep the cord dry until it falls off
• D. The cord stump will fall off in ten days

Correct answer: C

Rationale: The correct instruction to include in the teaching for cord care is to keep the cord dry until it falls off naturally. This helps prevent infection, as the cord typically falls off in 10-14 days, not within five days. Instructing the parent to contact the provider if the cord turns black (Choice A) is important to monitor for signs of infection. Cleaning the base of the cord with hydrogen peroxide daily (Choice B) is not recommended as it can delay healing. Stating that the cord stump will fall off in ten days (Choice D) provides a more accurate timeframe compared to the initial estimation of five days.

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