A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

Bradycardia

An increase in platelets

An increase in RBCs

An increase in neutrophils

Localized edema

Answer and Explanation

Correct Answer : D,E

A. Bradycardia is not typically a sign of infection. Infections usually lead to tachycardia (increased heart rate) rather than bradycardia.
B. An increase in platelets An increase in the platelet count can reflect malignancies, not infection.
C. An increase in RBCs is not typically associated with infection. Infection generally does not increase the number of red blood cells but may lead to changes in white blood cell counts.
D. An increase in neutrophils is a common response to bacterial infection. Neutrophils are white blood cells that increase in number to fight off infections.
E. Localized edema is often present in areas of infection due to inflammation and fluid accumulation in response to infection and tissue damage.

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Correct Answer is A

Explanation

A. Poor wound healing is a common manifestation of hyperglycemia. Elevated blood glucose levels can impair the immune response, slowing the healing process and making it more difficult for the body to repair tissues effectively.
B. A random blood glucose of 126 mg/dL is on the borderline of being considered hyperglycemic (diagnosed as diabetes if above 200 mg/dL). Hyperglycemia is often diagnosed based on fasting blood glucose levels, which should be above 126 mg/dL for diagnosis.
C. Decreased urinary output would more likely be associated with dehydration or other renal issues, not directly with hyperglycemia. Hyperglycemia tends to cause polyuria due to excess glucose being excreted through the urine.
D. Clammy skin is typically a sign of hypoglycemia, not hyperglycemia. In hyperglycemia, skin might be dry and flushed rather than clammy.

A. “I will turn my mother on her left side during the feeding.” B. “I will position the head of the bed 45 degrees during the feeding.” C. “I will allow the position my mother finds most comfortable during the feeding.” D. “I will elevate the head of the bed 10 degrees during the feeding.”

Correct Answer is B

Explanation

A. Turning the client on their left side is not the recommended position for administering enteral feedings. The client should be positioned with the head of the bed elevated to at least 30 to 45 degrees to reduce the risk of aspiration and promote proper digestion.
B. The head of the bed should be elevated to 30 to 45 degrees during enteral feedings. This position helps prevent aspiration by reducing the risk of gastric contents flowing back into the esophagus, and it promotes optimal digestion and absorption of the feeding.
C. Allowing the client to find a comfortable position during feeding is not appropriate because the head of the bed should be elevated to reduce the risk of aspiration. This position should be maintained regardless of the client's comfort level.
D. Elevating the head of the bed by only 10 degrees is insufficient. A higher angle (at least 30 degrees) is necessary to promote safe feeding and reduce the risk of aspiration.

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A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?

Correct Answer is B

Explanation

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A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)