After change-of-shift report, which patient will the nurse assess first?

A 68-year-old patient with type 2 diabetes who has peripheral neuropathy and complains of burning foot pain

A 35-year-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL

A 60-year-old patient with hyperosmolar hyperglycemic syndrome with dry oral mucosa and low urine output

A 19-year-old patient with type 1 diabetes who was admitted with possible dawn phenomenon

Answer and Explanation

The Correct Answer is C

Choice A reason: A 68-year-old patient with type 2 diabetes who has peripheral neuropathy and complains of burning foot pain is not the most urgent patient to assess. Peripheral neuropathy is a complication of diabetes that affects the nerves, especially in the feet and legs. It can cause symptoms such as numbness, tingling, burning, or pain. The nurse should assess the patient's foot condition, provide pain relief, and educate the patient on foot care. However, this patient is not in immediate danger, and can wait until the nurse finishes assessing the more critical patient.

Choice B reason: A 35-year-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL is not the most critical patient to assess. Type 1 diabetes is a condition where the pancreas does not produce any insulin, a hormone that helps the cells use glucose for energy. Patients with type 1 diabetes need to take insulin injections or use an insulin pump to control their blood glucose level. A blood glucose reading of 230 mg/dL is above the normal range of 70 to 130 mg/dL before meals, and indicates hyperglycemia (high blood sugar). The nurse should check the patient's insulin dose, monitor the patient's symptoms, and provide education on blood glucose management. However, this patient is not in life-threatening condition, and can wait until the nurse attends to the more serious patient.

Choice C reason: A 60-year-old patient with hyperosmolar hyperglycemic syndrome with dry oral mucosa and low urine output is the most important patient to assess. Hyperosmolar hyperglycemic syndrome (HHS) is a severe complication of diabetes that occurs when the blood glucose level is extremely high, usually above 600 mg/dL. HHS can cause dehydration, electrolyte imbalance, and coma. Dry oral mucosa and low urine output are signs of dehydration, which can lead to shock and organ failure. The nurse should assess the patient's vital signs, blood glucose level, fluid and electrolyte status, and neurological function. The nurse should also administer intravenous fluids, insulin, and electrolytes as prescribed by the health care provider. This patient is in a medical emergency, and needs immediate intervention.

Choice D reason: A 19-year-old patient with type 1 diabetes who was admitted with possible dawn phenomenon is not the most acute patient to assess. Dawn phenomenon is a condition where the blood glucose level rises in the early morning, usually between 2:00 AM and 8:00 AM. This is due to the release of hormones that increase the blood glucose level, such as growth hormone, cortisol, and glucagon. The nurse should review the patient's blood glucose records, adjust the insulin dose or timing, and provide education on how to prevent or manage the dawn phenomenon. However, this patient is not in a critical situation, and can wait until the nurse evaluates the more unstable patient.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E","F"]

Explanation

Choice A reason: This statement is true. Assessing mental status and level of consciousness is an important consideration for this treatment, as morphine can cause sedation, confusion, and respiratory depression. The nurse should monitor the client's orientation, alertness, and responsiveness, and use a sedation scale to evaluate the degree of sedation.

Choice B reason: This statement is true. Assessing urine output frequently is an important consideration for this treatment, as morphine can cause urinary retention, which can lead to bladder distension, infection, or kidney damage. The nurse should measure the client's urine output and check for signs of bladder fullness or discomfort.

Choice C reason: This statement is false. Monitoring potassium levels is not an important consideration for this treatment, as morphine does not affect the blood potassium level. Potassium is an electrolyte that is essential for the normal function of the heart, muscles, and nerves. Potassium imbalance can be caused by other factors, such as diuretics, vomiting, diarrhea, or acid-base disorders.

Choice D reason: This statement is true. Teaching the family that only the client can press the button for pain medication is an important consideration for this treatment, as PCA Pump allows the client to self-administer a preset dose of morphine within a specified time interval. The family should not press the button for the client, as this can result in overmedication, overdose, or addiction.

Choice E reason: This statement is true. Ensuring there is an order for Naloxone in case of overdose is an important consideration for this treatment, as Naloxone is an antidote that can reverse the effects of morphine in the event of an overdose. Naloxone can restore the client's breathing, blood pressure, and consciousness, and prevent death.

Choice F reason: This statement is true. Assessing CO2 levels is an important consideration for this treatment, as morphine can cause respiratory depression, which can lead to hypercapnia, or high blood carbon dioxide level. Hypercapnia can cause headache, drowsiness, confusion, and coma. The nurse should monitor the client's respiratory rate, depth, and rhythm, and use a capnograph or a blood gas analysis to measure the CO2 level.

A. Lower your potassium (K+) level, and it will have a laxative side effect B. Lower your potassium (K+) and have a diuretic side effect C. Lower your sodium (Na+) and have a laxative side effect D. Lower your sodium (Na+) and cause diarrhea

Correct Answer is A

Explanation

Choice A reason: This statement is true. Kayexalate is a medication that binds to potassium in the colon and exchanges it for sodium, thereby lowering the blood potassium level. It also has a laxative effect, which helps to eliminate the excess potassium in the stool.

Choice B reason: This statement is false. Kayexalate does not have a diuretic effect, which means it does not increase urine output or fluid loss. Diuretics are medications that act on the kidneys and help to remove excess fluid and sodium from the body.

Choice C reason: This statement is false. Kayexalate does not lower the blood sodium level, but rather increases it. This is because it exchanges potassium for sodium in the colon, which adds more sodium to the bloodstream.

Choice D reason: This statement is false. Kayexalate does not cause diarrhea, but rather a laxative effect, which means it stimulates bowel movements and softens the stool. Diarrhea is a condition where the stool is watery and frequent, and can cause dehydration and electrolyte imbalance.

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After change-of-shift report, which patient will the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client receiving morphine through a Patient Controlled Analgesia Pump (PCA Pump). The nurse knows that important considerations for this treatment include: SELECT ALL THAT APPLY

Correct Answer is ["A","B","D","E","F"]

Explanation

The nurse is administering Kayexalate to a client. The nurse explains that this medication will:

Correct Answer is A

Explanation

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