A nurse in a clinic is caring for a client who has gastroenteritis. The nurse compares the client's condition from two days ago and today. Which of the following changes should the nurse report to the provider?
The client is confused and appears weak.
The client's oral mucosa is dry and tongue is furrowed.
The client's lungs are clear bilaterally.
The client's abdomen is soft and nontender.
The Correct Answer is A
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these changes to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these changes to the provider as well, but they are not the most urgent ones.
Choice C reason: Clear lungs bilaterally are a normal finding and do not indicate any change in the client's condition. The nurse should document this finding, but it does not require reporting to the provider.
Choice D reason: A soft and non-tender abdomen is a normal finding and does not indicate any change in the client's condition. The nurse should document this finding, but it does not require reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: TPN is a form of nutrition that is delivered directly into the bloodstream through a central venous catheter. It is used for clients who have impaired or nonfunctional gastrointestinal tracts, such as those with acute kidney injury, bowel obstruction, or short bowel syndrome.
Choice B reason: The TPN does not necessarily have higher levels of vitamins than the recommended daily intake. The TPN is individually tailored to meet the client's nutritional needs, which may vary depending on their condition, weight, and laboratory values.
Choice C reason: The TPN does not ensure that the client's glucose level stays within the expected range. In fact, TPN can cause hyperglycemia due to the high concentration of dextrose in the solution. The client's blood glucose level should be monitored frequently and insulin should be administered as prescribed to prevent complications.
Choice D reason: The TPN is not higher in fats and protein, but lower in carbohydrates. The TPN contains a balanced mixture of macronutrients, including carbohydrates, proteins, and lipids, as well as micronutrients, such as electrolytes, vitamins, and minerals. The ratio of these components may vary depending on the client's nutritional needs and goals.
Correct Answer is B
Explanation
Choice D reason:A metallic taste in the mouth is not a recognized symptom of hyperglycemia. It may occur in other conditions, such as certain medication side effects, infections, or metabolic disorders, but it is not specific to diabetes or high blood glucose levels. Including this as a sign of hyperglycemia could lead to confusion or misinterpretation of symptoms.
Choice A reason: Anxiety is not a specific symptom of hyperglycemia, although it can be associated with stress or other psychological factors that can affect blood sugar levels. Anxiety can also be a symptom of hypoglycemia, or low blood sugar, which requires immediate treatment.
Choice B reason: Hyperventilation, characterized by deep and rapid breathing, is a critical manifestation of severe hyperglycemia, particularly in cases ofdiabetic ketoacidosis (DKA). When blood glucose levels are extremely high, the body may produce ketones, leading to metabolic acidosis. To compensate, the client may developKussmaul respirations, a type of hyperventilation aimed at expelling excess carbon dioxide. This is a medical emergency and requires immediate intervention. Teaching the client to recognize hyperventilation as a sign of severe hyperglycemia is essential for timely treatment and prevention of complications.
Choice C reason: Cool skin is not a symptom of hyperglycemia, but rather a sign of poor circulation, which can be a complication of diabetes. Diabetes can damage the blood vessels and nerves that supply blood and oxygen to the skin, especially in the feet and legs. This can lead to skin problems, infections, and ulcers.
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