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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Assisting the client to a low Fowler's position (15 to 30 degrees) is not appropriate for enteral feedings. The client should be positioned at a higher angle (30 to 45 degrees) to reduce the risk of aspiration and improve digestion during feeding.
B. Testing the pH of gastric aspirate is essential to confirm that the NG tube is in the correct position (i.e., the stomach). A pH of 1 to 4 indicates gastric placement, while higher pH values suggest the tube may be in the lungs or intestines. This is a crucial step to ensure safety before administering the feeding.
C. Discarding residual gastric contents is not the correct action. Residual gastric contents should be measured to assess gastric motility and tolerance to the feeding. The feeding should only be withheld if the residual volume is excessive, based on institutional guidelines.
D. Warming the feeding solution to body temperature is not always necessary, although it is often recommended to improve comfort and prevent cramping. The most important step is confirming tube placement and ensuring the feeding is safe.

A. Elevate the head of the client's bed 45° B. Massage the client's bony prominences C. Provide the client with a high-calorie diet D. Reposition the client every 4 hrs

Correct Answer is C

Explanation

A. Elevating the head of the bed to 45° may increase the risk for pressure injuries, especially on the sacrum, due to increased pressure and friction from sliding down. The head of the bed should be kept as low as possible, typically at 30°, to reduce this risk.
B. Massaging bony prominences is not recommended for clients at risk for pressure injuries. Massage can cause tissue damage and exacerbate pressure injury formation. It is better to avoid massaging areas prone to injury and instead use appropriate repositioning techniques.
C. Providing a high-calorie diet is essential for clients at risk for pressure injuries. Adequate nutrition, including high-protein and high-calorie foods, helps support skin integrity, wound healing, and overall tissue repair, reducing the risk of developing pressure injuries.
D. Repositioning the client every 4 hours is insufficient for preventing pressure injuries. Clients at risk should be repositioned at least every 2 hours to relieve pressure on vulnerable areas and promote circulation to the skin.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

Correct Answer is B

Explanation

A nurse is preparing for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?

A nurse is assisting with teaching a class about nutrients. The nurse should include that which of the following is a function of fats?

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?

A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?

A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?

A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications?

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?