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.

Exhibits

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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Checking urine for ketones is more relevant in DKA, not HHNS, as HHNS typically does not involve ketone production.
B. When blood glucose drops significantly, insulin infusion rates are usually decreased to prevent hypoglycemia and a rapid fall in glucose levels.
C. Increasing the insulin drip could cause hypoglycemia, as the client’s glucose is already decreasing.
D. A regular meal can be given when the client’s glucose levels are more stable and controlled, but meal timing should be coordinated with insulin adjustments.

A. Maintaining bed rest B. Administering a laxative C. Encouraging adequate fluid intake D. Assessing for hematuria

Correct Answer is C

Explanation

A. Maintaining bed rest is not typically required after an IVP unless otherwise indicated for the patient's condition.
B. Administering a laxative is not a standard intervention following an IVP unless the patient specifically requires it for bowel preparation or constipation.
C. Encouraging adequate fluid intake is crucial after the administration of contrast medium to help flush the kidneys and minimize the risk of contrast-induced nephropathy.
D. While assessing for hematuria may be appropriate, it is not a primary intervention directly related to the IVP procedure itself.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with hyperosmolar hyperglycemia nonketonic syndrome (HHNS) was admitted yesterday with a blood glucose level of 700 mg/dL. The clients blood glucose level is now 250 mg/dL. Which intervention should the nurse implement?

Correct Answer is B

Explanation

Following an intravenous pyelogram (IVP) using contrast medium, the nurse should anticipate incorporating which of the following measures the client's plan of care?

Correct Answer is C

Explanation

The client asks the nurse, "how did I get this urinary tract infection?" the nurse should explain that in most instances, cystitis is caused by:

Which question during the assessment of a patient who has diabetes will help the nurse identify autonomic neuropathy?

A nurse is caring for a client who has developed diseases of large and medium-sized blood vessels because of diabetes. Which of the following should the nurse anticipate if the client has cerebrovascular disease, cardiovascular disease, and peripheral vascular disease?

A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is teaching a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is teaching about self-monitoring to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is teaching a client who has a new diagnosis of Type 1 diabetes mellitus about self-administration of insulin. Which of the following instructions should the nurse include?

A nurse is preparing to administer aspirin 650 mg PO every 12 hr. The amount available is aspirin 325 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)