A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?

Place the client on contact precautions.

Start a high-fiber diet.

Administer an oral steroid.

Make the client NPO.

Answer and Explanation

The Correct Answer is B

A. Place the client on contact precautions: There is no indication of an infectious process requiring isolation. A normal glucose result does not suggest the need for precautions.
B. Start a high-fiber diet: The glucose level is within the normal range but on the higher end. Promoting a high-fiber diet can help maintain stable glucose levels and support long-term glucose control, especially if the client is at risk for impaired glucose tolerance.
C. Administer an oral steroid: Steroids can raise blood glucose levels and are not indicated in this context.
D. Make the client NPO: There is no reason to restrict oral intake based on a normal glucose result. NPO status is typically ordered for specific diagnostic procedures or when there is a risk of aspiration.

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 D

Explanation

Choice A rationale
While a self-care deficit may be a concern for clients with neuropathy, it is not the primary issue related to foot care. The priority is to prevent skin breakdown and injuries that can lead to more serious complications.
Choice B rationale
Impaired physical mobility is a common issue for clients with neuropathy, but it is not the primary concern for foot care. The focus should be on preventing skin breakdown and injuries.
Choice C rationale
Risk for infection is an important consideration, but it is secondary to the risk of impaired skin integrity. Preventing skin breakdown and injuries is the first step in reducing the risk of infection.
Choice D rationale
Risk for impaired skin integrity is the priority for promoting foot care in clients with neuropathy. Neuropathy can compromise the ability to detect injuries or wounds on the feet, leading to unnoticed wounds that can become infected and cause serious complications.
Preventing skin breakdown and injuries is crucial for maintaining foot health.

A. Provide a numeric pain scale. B. Ask the client to describe the pain. C. Observe body language and movement. D. Identify effective pain relief measures.

Correct Answer is B

Explanation

Choice A rationale
Providing a numeric pain scale helps quantify the intensity of pain but does not assess the quality of the pain. Quality refers to the characteristics and nature of the pain, which cannot be captured by a numeric scale alone.
Choice B rationale
Asking the client to describe the pain is the best approach to assess the quality of the pain. This allows the client to provide detailed information about the pain’s characteristics, such as its nature, location, and any associated symptoms.
Choice C rationale
Observing body language and movement can provide clues about pain but does not give a comprehensive understanding of the pain’s quality. Nonverbal cues are helpful but should be supplemented with the client’s verbal description.
Choice D rationale
Identifying effective pain relief measures is important for pain management but does not directly assess the quality of the pain. This step comes after understanding the pain’s characteristics.

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 reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Correct Answer is D

Explanation

To assess the quality of the client’s abdominal pain, which approach should the nurse use?

Correct Answer is B

Explanation

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

A 45-year-old client with breast cancer which has metastasized is receiving hospice care. The client is at home and the family is concerned about their loved one. The nurse assesses the client. Which of the following signs indicate that the client is near death?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain, the client denies having any pain. Which intervention should the nurse implement first?

The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking querry about the client’s laboratory results.Which response is best for the nurse to provide?