Correct Answer: C

Rationale:
Choice A is wrong because maintaining a semi-Fowler's position during testing is not necessary. You can sit or stand up straight, but make sure you do it the same way each time.
Choice B is wrong because placing tongue on the mouthpiece of the meter can block the air flow and affect the accuracy of the measurement. You should close your lips tightly on the mouthpiece instead. This is because a peak flow meter measures how fast you can push air out of your lungs when you blow out as hard and as fast as you can. This is called peak expiratory flow rate (PEFR) or peak expiratory flow (PEF). It shows how open the airways are in the lungs and can help detect early signs of worsening asthma.
Choice D is wrong because recording the average of the readings is not recommended. You should record the highest of the three readings on a sheet of paper, calendar, or in your asthma diary. This is your daily peak flow.

Correct Answer: C

Rationale: Monitoring for signs of lactic acidosis, such as muscle pain, weakness, or difficulty breathing, is critical, as it is a rare but serious side effect of metformin that requires immediate medical attention.
Choice A is wrong because, while taking metformin with meals can reduce gastrointestinal upset, the nurse should also advise starting with a low dose and gradually increasing to minimize side effects, not just taking it with meals.
Choice B is wrong because metformin is not typically associated with weight gain; it is weight-neutral or may promote slight weight loss.
Choice D is wrong because taking an additional dose after missing one is incorrect; the client should take the missed dose as soon as remembered unless it's close to the next dose, and consult the provider for guidance.

Correct Answer: B

Rationale: Monitoring for weight loss is critical with methylphenidate, a stimulant, as it commonly causes appetite suppression, which can lead to significant weight loss, especially in children with ADHD.
Choice A is incorrect because methylphenidate should be taken in the morning or early afternoon, as it can cause insomnia if taken at bedtime.
Choice C is incorrect because methylphenidate may take days to weeks to improve focus, not immediately.
Choice D is incorrect because methylphenidate can be taken with or without food; a high-fat meal may delay absorption but is not necessary.

Correct Answer: A,B

Rationale: Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client's medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer's solution are not indicated nursing actions for the client. Explanation: Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client's vital signs and symptoms closely. Documenting the blood product transfusion in the client's medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion. Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after. Titrating the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload: This may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client's condition, weight, and response to the transfusion, not on a fixed target. Starting an IV bolus of lactated Ringer's solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.

Correct Answer: C

Rationale:
Choice A is wrong because it is not the most urgent question to ask the client. While it is important to assess the client's social relationships and possible peer rejection, this can be done after addressing the client's safety and mental status.
Choice B is wrong because it is not relevant to the client's current condition and might make the client feel defensive or stigmatized. The nurse should avoid asking questions that imply blame or judgment and focus on the client's strengths and coping skills. This is the priority question for the nurse to ask the client because it assesses the client's risk for suicide, which is a serious and potentially life-threatening complication of conduct disorder. The nurse should use a direct and nonjudgmental approach when asking about suicidal ideation and plan.
Choice D is wrong because it is not appropriate for the nurse to ask the client in an emergency department setting. This question might imply that the client is responsible for their conduct disorder, which is a complex and multifactorial mental health condition. The nurse should collaborate with the client and their family to develop a behavior management plan that involves positive reinforcement, limit setting, and consistent consequences.