A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?

Bradycardia

Flushed skin

Decreased appetite

Tremors

Answer and Explanation

The Correct Answer is D

A. Bradycardia:
Low blood sugar levels can lead to bradycardia, a slower than normal heart rate.

B. Flushed skin:
Typically, low blood sugar levels might cause pallor or cool, clammy skin, rather than flushing.x

C. Decreased appetite:
Low blood sugar might result in increased hunger or a feeling of needing to eat rather than decreased appetite.

D. Tremors:
Hypoglycemia often presents with symptoms like tremors or shakiness due to the body's response to low blood sugar.

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Correct Answer is C

Explanation

A. To confirm the placement of the NG tube:
Confirming NG tube placement is typically done using other methods, such as auscultation of air insufflation, pH testing, or X-ray. Gastric residual measurement helps assess the status of the stomach content but is not the primary method for confirming tube placement.

B. To determine the client's electrolyte balance:
While the gastric contents do contain electrolytes, the primary purpose of measuring gastric residual is to assess gastric emptying and potential feeding intolerance. It is not the most accurate method for determining overall electrolyte balance.

C. To identify delayed gastric emptying:
This is the correct and primary purpose. Measuring gastric residual helps in identifying if there's a delay in the stomach emptying the previously administered feeding, which can inform the nurse about the client's tolerance to enteral nutrition.

D. To remove gastric acid that might cause dyspepsia:
The process of measuring gastric residual doesn't involve removing gastric acid. It's more about assessing how much of the previously administered feeding remains in the stomach. If there's a high residual volume, it may suggest delayed emptying or feeding intolerance. The focus is on adjusting the feeding plan rather than removing gastric acid.

A. "Inhale through the incentive spirometer 10 times with each use." B. "Use the incentive spirometer once every 4 hours." C. "Sit up at a 30-degree angle when using the incentive spirometer." D. "Hold your breath for 7 seconds when using the incentive spirometer."

Correct Answer is C

Explanation

A. "Inhale through the incentive spirometer 10 times with each use."
Explanation: The specific number of breaths can vary, and it's essential to follow the healthcare provider's or manufacturer's instructions. The emphasis is on taking slow, deep breaths rather than a specific count.

B. "Use the incentive spirometer once every 4 hours."
Explanation: The frequency of use may vary based on the healthcare provider's recommendations, the client's condition, and the healthcare setting. It's crucial to follow the individualized plan of care.

C. "Sit up at a 30-degree angle when using the incentive spirometer."
Explanation: This is correct. The client should sit upright to maximize lung expansion while using the incentive spirometer.

D. "Hold your breath for 7 seconds when using the incentive spirometer."
Explanation: The emphasis is on slow, deep inhalation rather than holding the breath for a specific duration. The primary goal is to improve lung function and prevent atelectasis.

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A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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