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A nurse in a medical clinic is caring for a client.

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurses' Notes

2 weeks ago, 0940:

Client presents to clinic with reports of feeling unwell for the past few weeks. Client states, "I have a sore that won't get better on my right foot." Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot; draining small amount of purulent drainage. Client awake and alert; chest clear to auscultation; heart tones audible with no abnormal heart tones heard. Client reports frequent urination, increased thirst, and recent 4.5 kg (10 lb) weight loss without trying. Client denies pain but reports experiencing nausea. BMI is 27.

Vital Signs

2 weeks ago, 0945:

Temperature 38.3° C (100.9°F)

Heart rate 104/min

Respiratory rate 18/min

Blood pressure 98/74 mm Hg

Oxygen saturation 97% on room air

Laboratory Results

2 weeks ago 1020:

WBC count 9,500/mm3 (5,000 to 10,000/mm3)

Blood glucose 250 mg/dL (74 to 106 mg/dL)

Triiodothyronine (T3) 200 mg/dL (70 to 205 mg/dL)

I have a sore that won't get better on my right foot."

Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot

draining small amount of purulent drainage

frequent urination

increased thirst

recent 4.5 kg (10 lb) weight loss without trying

Temperature 38.3° C (100.9°F)

Heart rate 104/min

Blood pressure 98/74 mm Hg

Blood glucose 250 mg/dL (74 to 106 mg/dL)

Answer and Explanation

The Correct Answer is ["C","D","E","F","G","H","I","J"]

Open wound on right foot with purulent drainage: A non-healing wound with purulent drainage suggests infection, which is a major concern in clients with hyperglycemia. Poor wound healing is common in diabetes due to impaired circulation and immune function.
Frequent urination, increased thirst, and unexplained 4.5 kg (10 lb) weight loss: Classic symptoms of hyperglycemia and possible diabetes mellitus. Polyuria and polydipsia result from osmotic diuresis due to high blood glucose levels, while unexplained weight loss may indicate the body breaking down fat and muscle for energy.
Temperature 38.3° C (100.9° F): Fever indicates a possible systemic infection. In diabetic clients, infections can progress rapidly and lead to complications such as cellulitis, osteomyelitis, or sepsis.
Heart rate 104/min: Tachycardia may be a response to fever, dehydration, or underlying infection. Persistent tachycardia could indicate worsening sepsis or hemodynamic instability.
Blood pressure 98/74 mm Hg: While not critically low, this blood pressure is on the lower end and could indicate early signs of dehydration from polyuria or systemic infection.
Blood glucose 250 mg/dL: Significantly elevated blood glucose suggests poor glycemic control, increasing the risk of infection, delayed wound healing, and diabetic ketoacidosis (DKA) if it continues to rise.:

Respiratory rate 18/min: A normal respiratory rate does not indicate respiratory distress or metabolic compensation.
Oxygen saturation 97% on room air: Oxygenation is within the normal range, suggesting no immediate hypoxia.
WBC count 9,500/mm³: Within the normal range, although an infection may still be present given the fever and purulent wound drainage.
Triiodothyronine (T3) 200 mg/dL: Within normal limits, ruling out thyroid dysfunction as a cause of symptoms.
BMI 27: Slightly overweight but not directly contributing to the acute condition.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Closing the inline clamp is necessary when the catheter is not in use to prevent air embolism, but it is not a required step before administering medication. The nurse should focus on flushing and checking for patency before medication administration.

B. Flushing the catheter with 10 mL of 0.9% sodium chloride before and after medication administration helps maintain patency, prevents occlusion, and ensures the catheter is functioning properly. This step is essential to avoid complications such as clot formation.

C. Applying a local anesthetic is not needed for routine medication administration through a nontunneled percutaneous central catheter. Anesthetic use is typically reserved for procedures like catheter insertion or painful dressing changes.

D. Donning sterile gloves is not required for medication administration through a central line. Clean gloves are sufficient, while sterile technique is reserved for dressing changes and catheter insertions.

A. 150 mL of greenish yellow NG drainage B. Client requests medication for nausea C. Urinary output of 250 mL over past 12 hr D. Hypoactive bowel sounds

Correct Answer is C

Explanation

A. 150 mL of greenish yellow NG drainage: This amount and color of drainage are expected after abdominal surgery, as bile-stained gastric contents can be present. It does not indicate a complication that requires provider notification.

B. Client requests medication for nausea: Nausea is a common postoperative symptom, often managed with antiemetics. While it should be addressed, it is not an urgent finding that requires immediate provider notification.

C. Urinary output of 250 mL over past 12 hr: Oliguria, defined as urine output less than 30 mL/hr (or less than 400 mL in 24 hr), suggests inadequate renal perfusion, possibly due to hypovolemia or acute kidney injury. This finding requires prompt provider notification.

D. Hypoactive bowel sounds: Reduced bowel activity is common after abdominal surgery due to anesthesia and opioid use. While monitoring is necessary, hypoactive sounds alone are not an urgent concern unless accompanied by other signs of ileus or obstruction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a medication for a client through a nontunneled percutaneous central catheter. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client who is 24 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

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