A nurse is caring for a client who is being admitted to t

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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 []

Potential Condition: The client’s elevated HbA1c (8.4%) and blood glucose level (235 mg/dL) indicate poorly controlled diabetes mellitus, which is likely leading to their symptoms of fatigue, blurred vision, dizziness, and headache. The client’s history of running out of insulin and glucose strips further supports the diagnosis of Type 1 diabetes mellitus, or possibly poorly controlled Type 2 diabetes mellitus.

Actions to Take:

Teach the client about the signs of hyperglycemia: Given the elevated blood glucose levels and lack of regular monitoring, it is essential to educate the client on recognizing signs of hyperglycemia to prevent complications such as diabetic ketoacidosis.

Assess the client’s feet for sensation: Diabetes can lead to neuropathy, increasing the risk of foot injuries and infections. Regular assessment of foot sensation is vital for early detection and prevention of complications.

Parameters to Monitor:

Fingerstick blood glucose: Frequent monitoring of blood glucose is necessary to assess the effectiveness of the insulin regimen and to make necessary adjustments.

Urinary output: Monitoring urinary output is important because polyuria is a common symptom of hyperglycemia. Decreased urine output may also indicate dehydration or renal impairment, both of which are complications of poorly controlled diabetes.

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Correct Answer is D

Explanation

A. A low temperature is not indicative of organ rejection; fever would be more concerning.

B. Weight loss is not a typical sign of acute organ rejection; weight gain due to fluid retention might be observed.

C. Insomnia is not specifically associated with organ rejection.

D. Oliguria (decreased urine output) is a significant sign of possible kidney transplant rejection, as it may indicate impaired kidney function.

A. Bubbling of the water in the water seal chamber with exhalation B. Movement of the trachea toward the unaffected side C. Scant serosanguinous drainage is found on the dressing D. Crepitus in the area above and surrounding the insertion site

Correct Answer is B

Explanation

A. Bubbling in the water seal chamber with exhalation can be normal as it indicates air is escaping from the pleural space; however, continuous bubbling may indicate an air leak and would need to be assessed.

B. Movement of the trachea toward the unaffected side is a sign of a tension pneumothorax, a life-threatening condition requiring immediate medical intervention. This tracheal deviation suggests that the pressure in the pleural space is increasing, pushing the mediastinum to the opposite side.

C. Scant serosanguinous drainage on the dressing is expected and not an immediate concern unless it becomes excessive.

D. Crepitus, or subcutaneous emphysema, indicates air leakage into the tissues but is not immediately life-threatening unless it is extensive and worsening rapidly.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

Correct Answer is D

Explanation

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer is B

Explanation

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