A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Condition Most Likely Experiencing:
- Type 1 diabetes
Actions to Take:
- Teach the client about the signs of hyperglycemia.
- Assess the client’s feet for sensation.
Parameters to Monitor:
- Fingerstick blood glucose
- Blood pressure
Rationale: The client has a high HbA1c (8.4%) and elevated blood glucose level (235 mg/dL), indicating poor blood glucose control. Symptoms such as fatigue, blurred vision, and dizziness suggest hyperglycemia, which can occur in clients with diabetes who have not been able to maintain regular glucose monitoring or insulin administration due to financial constraints. Teaching the client about hyperglycemia symptoms and checking feet for sensation is important due to the risk of complications like neuropathy. Monitoring blood glucose and blood pressure is essential for evaluating diabetes management and preventing complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A sonogram may help identify kidney abnormalities but is not the initial test for suspected infection.
B. A CT scan may be needed for further evaluation but is typically not the first test ordered.
C. A midstream urine culture is often the initial diagnostic test for suspected urinary tract infections or pyelonephritis, based on symptoms of chills, fever, and flank pain.
D. An intravenous pyelogram is used to detect structural abnormalities, such as renal calculi, but is not the initial test for infection symptoms.
Correct Answer is ["100"]
Explanation
To calculate the manual IV infusion rate in drops per minute (gtt/min) when using microtubing, you can use the following formula: IV Drip Rate (gtt/min) = (Volume to be infused (mL) x Drop factor (gtt/mL)) / Time (min). Since microtubing typically has a drop factor of 60 gtt/mL, and the nurse is looking to infuse 1L (1000 mL) of solution at a rate of 100 mL/hr, the time to infuse 100 mL would be 60 minutes. Plugging these values into the formula gives: IV Drip Rate (gtt/min) = (100 mL x 60 gtt/mL) / 60 min, which simplifies to 100 gtt/min. Therefore, the nurse should set the manual IV infusion to deliver 100 gtt/min.
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