A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)
Localized edema.
An increase in neutrophils.
An increase in platelets.
Bradycardia.
An increase in RBCS.
Correct Answer : A,B
Choice A rationale:
Localized edema is a common sign of infection. The body sends extra fluid to the area as part of the inflammatory response.
Choice B rationale:
An increase in neutrophils, a type of white blood cell, is a common response to infection. Neutrophils are part of the body’s immune response and work to fight off invading bacteria.
Choice C rationale:
An increase in platelets is not typically associated with infection. Platelets are involved in blood clotting, not the immune response.
Choice D rationale:
Bradycardia, or a slow heart rate, is not typically associated with infection. Infection usually causes an increased heart rate, not a decreased one.
Choice E rationale:
An increase in RBCs is not typically associated with infection. RBCs carry oxygen around the body, but their number does not usually change in response to infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Providing warm slipper-socks can help increase the client’s comfort by keeping their feet warm.
Choice B rationale:
Increasing the client’s oral fluid intake would not directly affect the temperature of their feet.
Choice C rationale:
Rubbing the client’s feet briskly for several minutes could potentially harm the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.
Choice D rationale:
Placing a moist heating pad under the client’s feet could potentially burn the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.
Correct Answer is B
Explanation
The correct answer is choice B. Inject 20 units of air into the NPH insulin vial.
Choice A rationale:
Replacing the needle for withdrawal with a safety needle is an important step to ensure safety and prevent needle-stick injuries. However, this action is not the first step when mixing two types of insulin. The initial steps involve preparing the insulin vials by injecting air into them.
Choice B rationale:
Injecting 20 units of air into the NPH insulin vial is the correct first step. This is because NPH insulin is a suspension and needs to be mixed properly. Injecting air into the vial helps to equalize the pressure, making it easier to withdraw the correct amount of insulin later. This step is crucial to ensure accurate dosing and proper mixing of the insulin.
Choice C rationale:
Injecting 10 units of air into the regular insulin vial is also necessary, but it is not the first step. The correct sequence is to first inject air into the NPH insulin vial, then into the regular insulin vial. This order helps prevent contamination of the regular insulin with NPH insulin.
Choice D rationale:
Withdrawing 10 units of insulin from the regular insulin vial is an important step, but it should be done after injecting air into both vials. The correct sequence ensures that the insulin is mixed properly and that the doses are accurate.
By following these steps in the correct order, the nurse ensures that the insulin is mixed safely and effectively, minimizing the risk of errors and ensuring proper glycemic control for the patient.
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