At 8 a.m. the nurse is reviewing patient assignments and notes one of the patients has a current blood glucose of 264. Breakfast is routinely served at 8:30. The following orders are noted in the chart. What action should the nurse take? Accucheck before meals and at bedtime with sliding scale insulin aspart SQ: Glucose 0-150 Administer 0 units; 151-200 Administer 2 units; 201-250 Administer 4 units: 251-300 Administer 6 units: 301-350 Administer 8 units; 351- 400 Administer 10 units; >400 Notify physician.

Provide 2 units insulin aspart 50

Provide 6 units insulin aspart 50

Provide 10 units insin apart SQ

Provide 4 units insulin aspart 50

Answer and Explanation

The Correct Answer is B

A. This option corresponds to the blood glucose range of 151-200. However, the patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 2 units would not be appropriate in this case.

B. The patient's current blood glucose level is 264, which falls into the range of 251-300. According to the sliding scale insulin aspart orders, for this range, 6 units should be administered. This option aligns with the patient's blood glucose level and the prescribed protocol.

C. This option corresponds to the blood glucose range of 351-400. The patient's blood glucose level of 264 does not fall into this range, so administering 10 units would be excessive and potentially lead to hypoglycemia.

D. This option corresponds to the blood glucose range of 201-250. The patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 4 units would not be sufficient to address the elevated blood glucose level.

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Correct Answer is B

Explanation

A. A client who has a calcium of 9.3 mg/dL - This calcium level is within the normal range (8.5-10.2 mg/dL) and does not indicate hypoparathyroidism.

B. A client who has a phosphate of 5.7 mg/dL - An elevated phosphate level is a manifestation of hypoparathyroidism. In hypoparathyroidism, there is a decrease in parathyroid hormone (PTH) production, which leads to decreased calcium absorption and increased phosphate levels.

C. A client who has a vitamin D of 25 ng/mL - This vitamin D level is within the normal range and does not specifically indicate hypoparathyroidism.

D. A client who has a magnesium of 1.8 mg/dL - This magnesium level is within the normal range and does not specifically indicate hypoparathyroidism.

A. Obtain a culture of the drainage. B. Check fine drainage for glucose. C. Document the amount of drainage. D. Notify the client's provider.

Correct Answer is B

Explanation

A. Obtaining a culture of the drainage may be necessary, but the immediate concern is to determine if the drainage is cerebrospinal fluid (CSF) or another type of fluid. Checking for glucose content is a rapid way to differentiate CSF from other fluids.

B. Correct. Clear drainage from the nose post-transsphenoidal hypophysectomy may indicate a CSF leak, which is a potential complication. Checking the drainage for glucose can help differentiate CSF from other fluids, as CSF contains glucose. If the drainage tests positive for glucose, it indicates the presence of CSF.

C. Documenting the amount of drainage is important, but determining the nature of the drainage (CSF or other fluid) takes precedence in this situation.

D. Notifying the client's provider is important, but the nurse should gather information about the drainage first by checking for glucose content. This information will be crucial for the healthcare provider to make decisions about further interventions

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results for four clients. The nurse should recognize which of the following clients has a manifestation of hypoparathyroidism?

Correct Answer is B

Explanation

A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)

A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.)

A patient is scheduled for surgery to remove a tumor of the anterior pituitary. Which hormone should the nurse expect to be affected by this surgery? Select all that apply.

A nurse is preparing a teaching session about reducing the risk of complications of diabetes mellitus. Which of the following information should the nurse plan to include in the teaching? (Select all that apply.)

A nurse is caring for a client who is 8 hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?

When preparing to provide morning medications, the nurse would give levothyroxine (Synthroid) ordered daily in which of the following ways?

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?