A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider?
Obtain capillary blood glucose level every 2 hr
Check the neurovascular status of the client's lower extremities every hour
Apply a cold pack to the client's ankle for 30 min every hour
Maintain the affected ankle elevated and immobilized
The Correct Answer is C
- A. Incorrect. Obtaining capillary blood glucose level every 2 hr is appropriate for a client who has type 1 diabetes mellitus, but it does not address the ankle injury.
- B. Incorrect. Checking the neurovascular status of the client's lower extremities every hour is important for a client who has an ankle injury, but it does not require clarification with the provider.
- C. Correct. Applying a cold pack to the client's ankle for 30 min every hour can reduce swelling and inflammation, but it can also impair circulation and increase the risk of tissue damage in a client who has diabetes mellitus. Therefore, the nurse should clarify this prescription with the provider before implementing it.
- D. Incorrect. Maintaining the affected ankle elevated and immobilized can help prevent further injury and promote healing, but it does not require clarification with the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Protective environment isolation precautions are used for immunocompromised patients to protect them from infections in the environment. It is not the appropriate precaution for a patient with bacterial meningitis, which is spread through respiratory droplets.
Choice B rationale:
Airborne precautions are used for diseases that are spread through the air and require a negative pressure room. Examples include tuberculosis and chickenpox. Bacterial meningitis is spread through respiratory droplets, not airborne transmission.
Choice C rationale:
Contact precautions are used for diseases that are spread by direct or indirect contact. Examples include MRSA and Clostridium difficile. Bacterial meningitis is primarily spread through respiratory droplets, not direct contact.
Choice D rationale:
Droplet precautions are used for diseases that are spread by respiratory droplets, such as influenza and bacterial meningitis. Patients with bacterial meningitis should be placed in a private room and wear a mask, and healthcare providers should wear a mask and eye protection when within 3 feet of the patient. This precaution helps prevent the spread of respiratory droplets containing the bacteria.
Correct Answer is A
Explanation
- A. This choice is correct because a child who has autism spectrum disorder often exhibits strict adherence to routines and rituals, and may become distressed or agitated when there are changes or disruptions to their usual patterns.
- B. This choice is incorrect because difficulty paying attention to tasks is not a specific manifestation of autism spectrum disorder, but rather a common symptom of attentiondeficit/hyperactivity disorder (ADHD). A child who has autism spectrum disorder may have difficulty focusing on tasks that are not of interest to them, but may also show intense concentration on tasks that are of interest to them.
- C. This choice is incorrect because disobedience to authority figures is not a specific manifestation of autism spectrum disorder, but rather a common behavior problem in children and adolescents. A child who has autism spectrum disorder may have difficulty understanding social cues and expectations, but may also show compliance and cooperation when given clear instructions and positive reinforcement.
- D. This choice is incorrect because excessive anxiety when separated from parents is not a specific manifestation of autism spectrum disorder, but rather a common symptom of separation anxiety disorder. A child who has autism spectrum disorder may have difficulty forming attachments and expressing emotions, but may also show affection and attachment to familiar people.
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