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 D

Explanation

A. 0715: This time is too soon after the administration of NPH insulin. NPH insulin typically has an onset of action of 1 to 2 hours, so hypoglycemia would not be expected this early.

B. 0730: Similar to option A, this time is still too soon for the onset of NPH insulin. The insulin has not yet started to lower blood glucose levels significantly.

C. 1200: By this time, the insulin would be in its peak action phase, not the onset phase. Hypoglycemia could occur during the peak, but the question specifically asks about the onset.

D. 0900: This time is within the expected onset period of NPH insulin, which is 1 to 2 hours after administration. Therefore, hypoglycemia could occur around this time as the insulin begins to lower blood glucose levels.

A. "Hold your breath for 7 seconds when using the incentive spirometer." B. "Sit up at a 30-degree angle when using the incentive spirometer." C. "Use the incentive spirometer once every 4 hours." D. "Inhale through the incentive spirometer 10 times with each use."

Correct Answer is A

Explanation

A. Hold your breath for 7 seconds when using the incentive spirometer is correct. To achieve optimal lung expansion, clients should inhale deeply and hold their breath for 3 to 5 seconds, though some guidelines may recommend up to 7 seconds, which helps to maximize the effectiveness of the inhalation.
B. Sit up at a 30-degree angle when using the incentive spirometer is not accurate. Clients should ideally sit upright or in a semi-Fowler’s position, but a 30-degree angle is not a strict requirement for using the spirometer. The key is to have an optimal posture for deep breathing.
C. Use the incentive spirometer once every 4 hours is incorrect. The incentive spirometer should be used every 1 to 2 hours while awake, not just once every 4 hours, to encourage frequent deep breathing and reduce the risk of atelectasis.
D. Inhale through the incentive spirometer 10 times with each use is not necessarily recommended. The general guidance is to perform 5 to 10 slow, deep breaths per session, but this can vary depending on the patient’s condition and specific instructions from their healthcare provider.

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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 administers subcutaneous NPH insulin at 0700 to a child who has diabetes. At which of the following times should the nurse observe for hypoglycemia caused by the onset of the medication?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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