A nurse is caring for a cent who has diabetes mellitus, type 1 Day 3 of hospital

0700

Temperature 37.3°C (981) Boot

Heart rate 121

118/62 mm Hg Temperature 30.8°

Be pressure 104mm Hg 0730

Fingerstick blood glucose, fasting 110 mg/dl. (74 to 106 mg/dL) NPH insulin 40 units subcutaneous administered into abdomen

0830

Client reports nausea with emesis: vomited morning meal 1130

Client reports feeling shaky, hungry, skin cool and diaphoretic Fingerstick blood glucose 55 mg/dL

HbA1c 8.01% (less than 7% greater than 129%)

Select the findings that require immediate follow up

Glucose at 1130

Client report of shakiness

Temperature

Oxygen saturation

Heart rate

HbA1c

Answer and Explanation

Correct Answer : A,B,E

A.   Glucose at 1130 - A fingerstick blood glucose level of 55 mg/dL indicates hypoglycemia and requires attention. This has to be addressed to prevent complications.
B.   Client report of shakiness - Shakiness, hunger, cool skin, and diaphoresis are classic symptoms of hypoglycemia, which requires immediate intervention to prevent further deterioration.
C.   Temperature - While changes in temperature may indicate infection or other issues, the client's symptoms of hypoglycemia are more urgent.
D.   Oxygen saturation - While oxygen saturation is important, it is not typically affected in hypoglycemic episodes and is therefore not the priority in this case.
E.   Heart rate - Tachycardia is a common symptom of hypoglycemia and should be addressed immediately
F.   HbA1c - HbA1c reflects long-term blood glucose control and does not require immediate follow-up in this acute situation.

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Correct Answer is C

Explanation

A. While dietary iron restrictions could contribute to iron deficiency anemia, chronic blood loss is a more direct consequence of ulcerative colitis.
B. Intestinal parasites could cause anemia through various mechanisms, but it's not directly related to ulcerative colitis unless the client has a co-infection.
C. Chronic blood loss is a common manifestation of ulcerative colitis due to inflammation and ulceration of the colon's mucosal lining. This chronic blood loss can lead to iron deficiency
anemia over time.

D. Intestinal malabsorption syndrome may occur in some cases of ulcerative colitis, but it's not typically the primary cause of anemia in these patients. Chronic blood loss is a more direct
mechanism.

A. Exhale slowly. B. Contract the pelvic muscles. C. Bear down. D. Take a sip of water.

Correct Answer is A

Explanation

A. Instructing the client to exhale slowly can help relax the pelvic floor muscles, making catheter insertion more comfortable.
B. Contracting the pelvic muscles (bearing down) would be counterproductive as it could cause resistance and make catheter insertion more difficult.
C. Bearing down (pushing) should be avoided as it can increase resistance and make catheter insertion more challenging.
D. Taking a sip of water is not typically necessary or indicated during urinary catheter insertion.

It is more important for the client to focus on relaxation techniques such as slow exhalation to aid in catheter insertion.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia?

Correct Answer is C

Explanation

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse provide to the client as the catheter is inserted?

Correct Answer is A

Explanation

A nurse is teaching a client diagnosed with hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching?

A charge nurse is looking to motivate the staff and to produce better outcomes on the unit. Which of the following behaviors by the charge nurse will produce those results?

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse?

A nurse is providing teaching to a client who has a history of pancreatitis. Which of the following food choices should the nurse instruct the client to avoid?

A nurse is caring for a client diagnosed with peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?

A nurse is teaching students about the use of isotonic solutions. The nurse recognizes which statements made by a student about isotonic solutions are correct. (SELECT ALL THAT APPLY)