A patient with type 2 diabetes and heart failure who is prescribed metformin extended release (Glucophage XR) once daily now has muscle aches, drowsiness, low blood pressure, and a slow irregular heartbeat. What is your best action?
a. Assess the patient's blood glucose level and prepare to administer intravenous (IV) glucose.
b. Assess the patient's blood glucose level and prepare to administer insulin.
c. Hold the dose and notify the prescriber immediately.
d. Administer the drug at bedtime to prevent falls.
ANS: C
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The nurse is conducting a home visit on a newborn. What observation would require the nurse to provide further education?
a. The caregiver warms the bottle and tests heat on the inside of the wrist. b. The parents state the infant is sleeping with them until they buy a crib. c. One parent states that when the child gets frustrating, the other parent takes over. d. Caregivers consistently wash their hands before holding the baby.
A patient has been admitted to the critical care unit after a stroke. After "failing" a swallow study, the patient is placed on enteral feedings. Following placement of a nasogastric tube for tube feeding, what is the next critical step?
a. Administer medications. b. Cap off and wait 24 hours before starting feedings. c. Obtain a chest radiograph. d. Start the tube feeding.
The nurse is determining if a recurring client problem could be considered for a nursing diagnosis. The organization that develops and approves nursing diagnoses is the:
a. ANA. b. NANDA. c. AMA. d. TJC.
A patient tells the nurse that many of her family members have a type of anemia that is genetic. What should the nurse realize will occur in this patient?
1. The patient will develop the disease only if there is a mutation in the gene. 2. The patient will develop the same type of anemia. 3. The patient will die from the anemia. 4. The patient will develop the disease only if the gene translocates.