A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?

Kussmaul respirations

Diaphoresis

Decreased skin turgor

Ketonuria

Answer and Explanation

The Correct Answer is B

Choice A reason: This is an incorrect finding, because Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Kussmaul respirations are deep and rapid breathing that help the body eliminate excess carbon dioxide and acid.

Choice B reason: This is the correct finding, because diaphoresis is a sign of hypoglycemia, which is a condition that occurs when the blood glucose is too low. Diaphoresis is excessive sweating that results from the activation of the sympathetic nervous system and the release of epinephrine, which stimulate the body to increase the blood glucose level.

Choice C reason: This is an incorrect finding, because decreased skin turgor is a sign of dehydration, which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Decreased skin turgor is a loss of elasticity and firmness of the skin that results from the loss of fluid and electrolytes through the urine and the skin.

Choice D reason: This is an incorrect finding, because ketonuria is a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Ketonuria is the presence of ketones in the urine, which are acidic substances that are produced when the body breaks down fat for energy due to the lack of insulin.

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Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Checking and documenting the client's vital signs is a correct action, because it provides a baseline for comparison and helps to monitor for any signs of adverse reactions to the transfusion.

Choice B reason: Ensuring that the client's IV site uses a 22-gauge needle is an incorrect action, because a larger gauge needle (18- or 20-gauge) is preferred for blood transfusions to prevent hemolysis of the RBCs.

Choice C reason: Verifying that the blood type and Rh of the packed RBCs are checked by two nurses is a correct action, because it is a standard safety procedure to prevent transfusion errors and ensure compatibility.

Choice D reason: Obtaining a bag of lactated Ringer's IV solution is an incorrect action, because only normal saline (0.9% sodium chloride) should be used as the IV solution for blood transfusions. Other solutions may cause hemolysis or clotting of the blood.

Choice E reason: Providing the RN with tubing that has a filter is a correct action, because a filter is required for blood transfusions to remove any clumps or debris from the blood.

A. “Adults receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox.” B. “Herpes zoster is not contagious to individuals who received MMR vaccine as an infant.” C. “A client who has herpes zoster is not contagious if blisters are present on the skin.” D. “Herpes zoster is contagious to people who have never had chickenpox.”

Correct Answer is D

Explanation

Choice A reason: This is a false statement, because adults do not receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox. Herpes zoster is caused by the reactivation of the varicella-zoster virus, which remains dormant in the nerve cells after a primary infection with chickenpox.

Choice B reason: This is a false statement, because herpes zoster is not prevented by the MMR vaccine, which protects against measles, mumps, and rubella. Herpes zoster is prevented by the varicella vaccine, which is given separately from the MMR vaccine.

Choice C reason: This is a false statement, because a client who has herpes zoster is contagious if blisters are present on the skin. The blisters contain the varicella-zoster virus, which can be transmitted through direct contact or airborne droplets.

Choice D reason: This is the correct statement, because herpes zoster is contagious to people who have never had chickenpox. People who have never had chickenpox can contract the varicella-zoster virus from a person who has herpes zoster and develop chickenpox as a primary infection.

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A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["A","C","E"]

Explanation

A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who has herpes zoster. The AP asks the nurse if herpes zoster is contagious. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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