The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the health care provider?

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Question 1 of 5

The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the health care provider?

Correct Answer: D

Rationale: The correct answer is D: The patient has chest pressure when walking. This symptom could indicate cardiac issues, a known side effect of rosiglitazone. Reporting this immediately is crucial to prevent potential serious complications. A: The patient's blood pressure is 154/92. While high, it is not an immediate concern unless accompanied by other symptoms. B: The patient has a history of emphysema. Relevant but not urgent in this scenario. C: The patient's blood glucose is 86 mg/dL. Within the normal range and not a priority compared to chest pressure. In summary, choice D is correct as it addresses a potentially severe side effect of the medication that requires immediate attention. Choices A, B, and C are not as urgent or directly related to the medication's side effects.

Question 2 of 5

A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Correct Answer: D

Rationale: The correct answer is D: Confine the fire. This is the most appropriate action because the nurse's first priority is to ensure the safety of the client by containing the fire to prevent it from spreading and causing harm. By confining the fire, the nurse can help protect the client and other individuals in the vicinity. Activating the fire alarm (choice A) may be necessary but should come after the fire is confined. Extinguishing the fire (choice B) may put the nurse and client at risk without proper training or equipment. Evacuating the client (choice C) should only be done if the fire cannot be quickly and safely confined.

Question 3 of 5

When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?

Correct Answer: B

Rationale: The correct answer is B: Perform the irrigation using a 20-mL syringe. This is the correct action because using a 20-mL syringe allows for precise and controlled instillation of the irrigation fluid into the catheter. Using a smaller syringe helps prevent excessive pressure within the catheter, reducing the risk of trauma or damage to the client's urinary system. A: Positioning the client in a side-lying position is not essential for open irrigation technique, as long as the client is comfortable and the procedure can be safely performed. C: Instilling 15 mL of irrigation fluid with each flush may not be appropriate as the volume needed may vary based on the client's condition. D: Although measuring and recording the amount of irrigant used is important for documentation purposes, it is not the immediate action to ensure the safe and effective irrigation of the catheter.

Question 4 of 5

A client with limited mobility in their lower extremities is at risk for skin breakdown. Which of the following actions should the nurse take to prevent skin breakdown?

Correct Answer: B

Rationale: The correct answer is B: Increase the client's intake of carbohydrates. Adequate nutrition, including carbohydrates, is essential for skin health and wound healing. Carbohydrates provide energy for the body's healing processes. Skin breakdown can be prevented by ensuring the client has a well-balanced diet. A: Placing the client in high-Fowler's position is not directly related to preventing skin breakdown in this scenario. C: Massaging areas of skin that are darker than the surrounding skin tissue with lotion may cause more harm than good, as it can increase the risk of skin breakdown. D: Having the client use a trapeze bar when changing position is important for mobility but does not directly address the prevention of skin breakdown.

Question 5 of 5

A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

Correct Answer: C

Rationale: Rationale: The correct answer is C because it accurately describes the situation based on the information provided. Documenting that the client was trying to get out of bed aligns with the roommate's report of the incident. This statement is factual and relevant to the client's condition. Summary: A: Incident report completed - Not relevant to documenting the client's actions during the fall. B: Client climbed over the side rails - Assumes an action not reported by the roommate. D: Client found lying on floor - Describes the outcome, but does not explain the cause of the fall.

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