Nursing Elites

1. A nurse is administering metformin to a client with type 2 diabetes. Which of the following adverse effects should the nurse monitor for in this client?

• A. Diarrhea
• B. Hyperglycemia
• C. Hypoglycemia
• D. Lactic acidosis

Correct answer: D

Rationale: The correct answer is D, Lactic acidosis. Lactic acidosis is a rare but serious adverse effect of metformin use. Metformin is not known to cause hyperglycemia or hypoglycemia. Diarrhea is a common gastrointestinal side effect of metformin but is not as serious as lactic acidosis, which requires immediate medical attention.

2. A nurse is caring for a client prescribed enoxaparin for deep vein thrombosis prophylaxis. Which of the following client assessments requires immediate intervention?

• A. Platelet count of 95,000/mm³
• B. Blood pressure of 145/90 mmHg
• C. Heart rate of 95 beats per minute
• D. Pain at the injection site

Correct answer: A

Rationale: A platelet count of 95,000/mm³ requires immediate intervention as it is low and increases the risk of bleeding, which is a potential complication of enoxaparin therapy. Low platelet counts can predispose the patient to hemorrhage, and administering anticoagulants like enoxaparin in such cases can further increase the bleeding risk. Monitoring platelet counts is crucial during anticoagulant therapy to prevent serious bleeding complications. The other options do not pose immediate risks related to enoxaparin therapy. A slightly elevated blood pressure, a heart rate of 95 beats per minute, and pain at the injection site are common findings that may not warrant immediate intervention in this context.

3. A nurse is preparing to administer furosemide to a client. Which of the following findings indicates the client may be at risk for an adverse effect of the medication?

• A. Hypertension
• B. Hypokalemia
• C. Increased urine output
• D. Hyperglycemia

Correct answer: B

Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can cause potassium depletion, leading to hypokalemia, which is a common adverse effect. Hypokalemia can result in serious complications like cardiac arrhythmias. Choices A, C, and D are not directly associated with the adverse effects of furosemide. Hypertension is a condition that furosemide is often used to treat, increased urine output is an expected effect of furosemide, and hyperglycemia is not a typical adverse effect of this medication.

4. A nurse is caring for a client prescribed methotrexate for rheumatoid arthritis. Which of the following client history findings requires the nurse to question the administration of this medication?

• A. Osteoporosis
• B. Hypertension
• C. Peptic ulcer disease
• D. Immunosuppression

Correct answer: C

Rationale: The correct answer is C: Peptic ulcer disease. Methotrexate can exacerbate peptic ulcer disease, leading to serious complications. This finding warrants questioning the administration of methotrexate to prevent harm to the client. Choices A, B, and D are not directly contraindicated with methotrexate use. Osteoporosis, hypertension, and immunosuppression are not typically reasons to question the administration of methotrexate for rheumatoid arthritis.

5. A nurse is caring for a client receiving IV vancomycin. The nurse notes flushing of the client's neck and chest. Which of the following actions should the nurse take?

• A. Stop the infusion
• B. Document the findings as a harmless reaction
• C. Slow the infusion rate
• D. Administer diphenhydramine

Correct answer: C

Rationale: The correct action for the nurse to take when a client receiving IV vancomycin shows flushing of the neck and chest is to slow the infusion rate. Flushing is a common sign of Red Man Syndrome, which is associated with rapid infusions of vancomycin. Slowing down the infusion rate can help prevent further flushing and the development of Red Man Syndrome. Stopping the infusion (Choice A) may be too drastic if the symptoms are mild and can be managed by slowing the rate. Documenting the findings as a harmless reaction (Choice B) is incorrect because flushing should be addressed promptly to prevent complications. Administering diphenhydramine (Choice D) is not the initial or best intervention for flushing associated with vancomycin; slowing the infusion rate is the priority.

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