Nursing Elites

1. A nurse is planning care for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?

• A. Fasting blood glucose
• B. Carbohydrate intake
• C. Hematocrit
• D. Weight

Correct answer: D

Rationale: The correct answer is D: Weight. Weight monitoring is essential to assess the effectiveness of desmopressin therapy, as fluid retention is a common side effect. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin therapy for diabetes insipidus. Monitoring carbohydrate intake (choice B) may be important in diabetes management but is not specific to desmopressin therapy. Hematocrit (choice C) monitoring is not a primary concern when managing diabetes insipidus with desmopressin.

2. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?

• A. Excessive sweating.
• B. Increased urinary frequency.
• C. Dry cough.
• D. Metallic taste in the mouth.

Correct answer: A

Rationale: The correct adverse effect of sertraline that the nurse should include in the teaching is excessive sweating. Sertraline is known to cause this side effect in some individuals. Increased urinary frequency (choice B) is not a commonly reported adverse effect of sertraline. Dry cough (choice C) and metallic taste in the mouth (choice D) are also not typically associated with sertraline use. Therefore, the nurse should focus on educating the client about the potential adverse effect of excessive sweating.

3. A nurse is caring for a client who has chronic kidney disease and is experiencing fluid volume overload. Which of the following findings should the nurse expect?

• A. Decreased blood pressure
• B. Increased urine output
• C. Decreased heart rate
• D. Increased heart rate

Correct answer: A

Rationale: In a client with chronic kidney disease experiencing fluid volume overload, the nurse should expect a decreased blood pressure. Fluid volume overload can lead to poor cardiac output, which in turn can cause a decrease in blood pressure. Choices B, C, and D are incorrect. Increased urine output is not expected in fluid volume overload; decreased heart rate is not typically associated with fluid volume overload; and an increased heart rate is more commonly seen in response to fluid overload to compensate for the decreased cardiac output.

4. A client with a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water daily.
• B. Wear shoes that are one size larger than your normal size.
• C. Wear cotton socks to keep your feet dry.
• D. Trim your toenails straight across.

Correct answer: D

Rationale: The correct answer is D: "Trim your toenails straight across." This instruction is essential to prevent ingrown toenails in clients with diabetes. Soaking feet in warm water daily (choice A) may increase the risk of skin breakdown and infection. Wearing shoes one size larger than normal (choice B) can lead to friction and cause blisters. While wearing cotton socks (choice C) is generally recommended, the emphasis should be on moisture-wicking materials rather than just cotton.

5. A nurse is caring for a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Keep the head of the bed elevated to 15 degrees.
• B. Change the feeding bag every 48 hours.
• C. Administer the feeding through a large-bore syringe.
• D. Flush the tube with 0.9% sodium chloride every 4 hours.

Correct answer: D

Rationale: The correct action the nurse should take is to flush the tube with 0.9% sodium chloride every 4 hours. This helps maintain patency and prevents clogs during enteral feedings. Keeping the head of the bed elevated to 15 degrees (Choice A) is important for preventing aspiration but is not directly related to tube care. Changing the feeding bag every 48 hours (Choice B) is not a standard practice as the bag should be changed every 24 hours to prevent bacterial growth. Administering the feeding through a large-bore syringe (Choice C) is incorrect as enteral feedings should be given through an appropriate feeding pump for accuracy and safety.

Similar Questions