Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Take metformin with the morning and evening meal.
A: Taking metformin with the morning and evening meal is a correct statement for the nurse to include, as this can improve the absorption and effectiveness of metformin and reduce the risk of gastrointestinal side effects. Therefore, this is a correct choice.
B. Use sliding scale insulin for frequent blood glucose elevations.
B: Using sliding scale insulin for frequent blood glucose elevations is not a correct statement for the nurse to include, as this is not recommended for clients with type 2 DM who are taking metformin. This can cause hypoglycemia and complicate the management of blood glucose levels. This is an incorrect choice.
C. Recognize signs and symptoms of hypoglycemia.
C: Recognizing signs and symptoms of hypoglycemia is a correct statement for the nurse to include, as this can help the client identify and treat low blood glucose levels, which can occur with metformin use or other factors such as exercise, fasting, or alcohol intake. Therefore, this is another correct choice.
D. Report persistent polyuria to the health care provider.
D: Reporting persistent polyuria to the health care provider is a correct statement for the nurse to include, as this can indicate poor glycemic control or a complication of DM such as diabetic ketoacidosis or nephropathy. Therefore, this is another correct choice.
E. Take an additional dose for signs of hyperglycemia.
E: Taking an additional dose for signs of hyperglycemia is not a correct statement for the nurse to include, as this can cause overdose or toxicity of metformin, which can lead to lactic acidosis and renal failure. This is another incorrect choice.
This question is an excerpt from Nurse Dive's nursing test bank - HESI Exit II Proctored Exam. Take the full exam now
Full Explanation
Choice A: Taking metformin with the morning and evening meal is a correct statement for the nurse to include, as this can improve the absorption and effectiveness of metformin and reduce the risk of gastrointestinal side effects. Therefore, this is a correct choice.
Choice B: Using sliding scale insulin for frequent blood glucose elevations is not a correct statement for the nurse to include, as this is not recommended for clients with type 2 DM who are taking metformin. This can cause hypoglycemia and complicate the management of blood glucose levels. This is an incorrect choice.
Choice C: Recognizing signs and symptoms of hypoglycemia is a correct statement for the nurse to include, as this can help the client identify and treat low blood glucose levels, which can occur with metformin use or other factors such as exercise, fasting, or alcohol intake. Therefore, this is another correct choice.
Choice D: Reporting persistent polyuria to the health care provider is a correct statement for the nurse to include, as this can indicate poor glycemic control or a complication of DM such as diabetic ketoacidosis or nephropathy. Therefore, this is another correct choice.
Choice E: Taking an additional dose for signs of hyperglycemia is not a correct statement for the nurse to include, as this can cause overdose or toxicity of metformin, which can lead to lactic acidosis and renal failure. This is another incorrect choice.
Similar Questions
The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?
A. Center attention on positive upbeat music.
A: Centering attention on positive upbeat music is not a specific instruction for the nurse to include, as this is a general coping strategy that may or may not be helpful for this client. This is a distractor choice.
B. Find outlets for more social interaction.
B: Finding outlets for more social interaction is not a relevant instruction for the nurse to include, as this may not address the underlying causes of anxiety or stress for this client. This is another distractor choice.
C. Practice using muscle relaxation techniques.
C: Practicing using muscle relaxation techniques is an appropriate instruction for the nurse to include, as this can help reduce physical tension and promote calmness and relaxation for this client. Therefore, this is the correct choice.
D. Think about reasons the episodes occur.
D: Thinking about reasons the episodes occur is not a helpful instruction for the nurse to include, as this can increase rumination and anxiety for this client. This is another distractor choice.
Full Explanation
Choice A: Centering attention on positive upbeat music is not a specific instruction for the nurse to include, as this is a general coping strategy that may or may not be helpful for this client. This is a distractor choice.
Choice B: Finding outlets for more social interaction is not a relevant instruction for the nurse to include, as this may not address the underlying causes of anxiety or stress for this client. This is another distractor choice.
Choice C: Practicing using muscle relaxation techniques is an appropriate instruction for the nurse to include, as this can help reduce physical tension and promote calmness and relaxation for this client. Therefore, this is the correct choice.
Choice D: Thinking about reasons the episodes occur is not a helpful instruction for the nurse to include, as this can increase rumination and anxiety for this client. This is another distractor choice.
A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?
A. Review the need for the UAP to wear a face mask while in close contact with the client.
Choice A reason: Review the need for the UAP to wear a face mask while in close contact with the client. Influenza is a respiratory virus that spreads mainly by droplets made when people with flu cough, sneeze or talk. A face mask can help block the spread of these droplets.
B. Remind the UAP to apply a fitted respirator mask before entering the client’s room.
Choice B reason: Reminding the UAP to apply a fitted respirator mask before entering the client’s room is not necessary for standard influenza precautions. Respirator masks are more commonly used for airborne precautions, such as tuberculosis or measles, not for influenza.
C. Assign the UAP to provide care for another client and assume full care of the client.
Choice C reason: Assigning the UAP to provide care for another client and assuming full care of the client is not indicated unless the UAP is not following proper infection control procedures. There is no evidence of that in the scenario provided.
D. Instruct the UAP to notify the nurse of any changes in the client’s respiratory status.
Choice D reason: Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is important, but it is not the immediate action related to infection control. The priority is to prevent the spread of infection.
Full Explanation
The correct answer is A:
Choice A reason: Review the need for the UAP to wear a face mask while in close contact with the client. Influenza is a respiratory virus that spreads mainly by droplets made when people with flu cough, sneeze or talk. A face mask can help block the spread of these droplets.
Choice B reason: Reminding the UAP to apply a fitted respirator mask before entering the client’s room is not necessary for standard influenza precautions. Respirator masks are more commonly used for airborne precautions, such as tuberculosis or measles, not for influenza.
Choice C reason: Assigning the UAP to provide care for another client and assuming full care of the client is not indicated unless the UAP is not following proper infection control procedures. There is no evidence of that in the scenario provided.
Choice D reason: Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is important, but it is not the immediate action related to infection control. The priority is to prevent the spread of infection.
A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has highest priority?
A. Mark an outline of the “olive-shaped” mass in the right epigastric area.
A is incorrect because marking an outline of the “olive-shaped” mass in the right epigastric area is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The “olive-shaped” mass is a palpable sign of pyloric stenosis, but it does not require any intervention before surgery.
B. Initiate a continuous infusion of IV fluids per prescription.
B is correct because initiating a continuous infusion of IV fluids per prescription has highest priority for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. Pyloric stenosis causes projectile vomiting and dehydration, which can lead to metabolic alkalosis and electrolyte imbalance. The infant needs IV fluids to correct these abnormalities and prevent complications.
C. Monitor amount of intake and infant's response to feedings.
C is incorrect because monitoring amount of intake and infant's response to feedings is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The infant may have difficulty feeding due to vomiting and gastric distension, which can worsen their dehydration and malnutrition. The infant may need to be kept NPO (nothing by mouth) before surgery.
D. Instruct parents regarding care of the incisional area.
D is incorrect because instructing parents regarding care of the incisional area is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The incisional area will need proper care after surgery, but this can be taught later when the infant is stable and ready for discharge.
Full Explanation
Choice B is correct because initiating a continuous infusion of IV fluids per prescription has highest priority for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. Pyloric stenosis causes projectile vomiting and dehydration, which can lead to metabolic alkalosis and electrolyte imbalance. The infant needs IV fluids to correct these abnormalities and prevent complications.
Choice A is incorrect because marking an outline of the “olive-shaped” mass in the right epigastric area is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The “olive-shaped” mass is a palpable sign of pyloric stenosis, but it does not require any intervention before surgery.
Choice C is incorrect because monitoring amount of intake and infant's response to feedings is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The infant may have difficulty feeding due to vomiting and gastric distension, which can worsen their dehydration and malnutrition. The infant may need to be kept NPO (nothing by mouth) before surgery.
Choice D is incorrect because instructing parents regarding care of the incisional area is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The incisional area will need proper care after surgery, but this can be taught later when the infant is stable and ready for discharge.