Nursing Elites

1. A client with diabetes mellitus is prescribed metformin. What teaching should the nurse include?

• A. Take the medication with meals to reduce gastrointestinal upset.
• B. Monitor renal function regularly due to the risk of lactic acidosis.
• C. Avoid alcohol consumption while taking this medication.
• D. Check blood glucose levels regularly to ensure proper management.

Correct answer: B

Rationale: The correct teaching for a client prescribed metformin includes monitoring renal function regularly due to the risk of lactic acidosis, especially in clients with impaired kidney function. While taking metformin with meals can reduce gastrointestinal upset, it is not the highest priority teaching point. Avoiding alcohol is generally recommended but not the most critical teaching point in this scenario. Checking blood glucose levels regularly is important for diabetes management but not specifically related to metformin use.

2. A client's chest tube insertion site has crepitus (crackling sensation) upon palpation. What is the nurse's next step?

• A. Apply a pressure dressing to the chest tube site.
• B. Administer an oral antihistamine.
• C. Assess the client for allergies to cleaning agents.
• D. Measure the area of swelling and crackling.

Correct answer: D

Rationale: The correct next step for the nurse is to measure the area of crepitus. Crepitus indicates subcutaneous emphysema, which is a serious condition requiring monitoring. Applying a pressure dressing (Choice A) could worsen the condition by trapping air under the skin. Administering an oral antihistamine (Choice B) is not indicated for crepitus. Assessing for allergies to cleaning agents (Choice C) is not the priority when dealing with crepitus and subcutaneous emphysema.

3. The nurse is developing a plan of care for a client who reports tingling in the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?

• A. The client will walk 30 minutes three times a week
• B. The client will demonstrate understanding of proper shoe fit
• C. The client will perform foot care daily
• D. The client's blood pressure readings will be less than 160/90 mmHg

Correct answer: D

Rationale: Controlling blood pressure is critical in managing peripheral vascular disease, as elevated pressure can exacerbate vascular damage and complications. While foot care, shoe fit, and exercise are important, lowering blood pressure is a primary goal. Proper blood pressure management helps in preventing further damage to the blood vessels and reduces the risk of complications associated with peripheral vascular disease, making it the most crucial outcome to include in the plan of care for this client.

4. Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?

• A. Witness the consent and sign the form as a witness
• B. Inform the client of alternatives to the procedure
• C. Explain the procedure in detail to the client
• D. Determine that the surgical consent form has been signed and is included in the client's record

Correct answer: D

Rationale: The nurse's legal responsibility is to ensure that informed consent has been obtained by verifying that the client has signed the form and that it is included in the record. Witnessing the consent and signing as a witness is not the nurse's role, as this is typically done by a neutral party. Informing the client of alternatives to the procedure and explaining the procedure in detail are responsibilities of the healthcare provider performing the surgery, not the nurse.

5. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give the child sugar water only.
• B. Offer oral rehydration solution every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy per prescription.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant diagnosed with hypertrophic pyloric stenosis and experiencing projectile vomiting is to maintain intravenous fluid therapy. Intravenous fluids are crucial for rehydrating an infant suffering from dehydration due to rapid fluid loss from vomiting. Instructing the mother to provide sugar water only (choice A) is inappropriate and insufficient for rehydration. Offering oral rehydration solution every 2 hours (choice B) may not be effective if the infant continues to vomit. Providing Pedialyte feedings via nasogastric tube (choice C) may also not be as effective as intravenous fluid therapy in rapidly replenishing fluids and stabilizing the child's condition.

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