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During a routine medical evaluation, a client is found to have a random blood glucose level of 310 mg/dL. Which client statements are concerning to the nurse? Select all that apply.

I sleep at least 8 hours each night.

I cannot seem to quench my thirst.

I have to void nearly every hour.

At times my vision is blurry.

I have lost 10 pounds without even trying.

Answer and Explanation

Correct Answer : B

Choice A Reason:

I sleep at least 8 hours each night.

This statement is not concerning because getting adequate sleep is generally a sign of good health. It does not directly relate to symptoms of high blood glucose levels. Therefore, this choice is not relevant to the nurse’s concerns regarding the client’s elevated blood glucose level.

Choice B Reason:

I cannot seem to quench my thirst.

This statement is concerning because excessive thirst, known as polydipsia, is a common symptom of high blood glucose levels or hyperglycemia. When blood glucose levels are elevated, the body tries to eliminate the excess glucose through urine, leading to dehydration and increased thirst. This symptom indicates that the client’s blood glucose levels may be poorly controlled, which requires medical attention.

Choice C Reason:

I have to void nearly every hour.

Frequent urination, or polyuria, is another symptom of high blood glucose levels. When there is too much glucose in the blood, the kidneys work harder to filter and absorb it. When they can’t keep up, the excess glucose is excreted into the urine, pulling fluids from the tissues and causing frequent urination. This symptom is a clear indicator of hyperglycemia and needs to be addressed by the nurse.

Choice D Reason:

At times my vision is blurry.

Blurred vision can be a symptom of high blood glucose levels. Elevated glucose levels can cause the lens of the eye to swell, leading to changes in vision. This symptom is concerning because it suggests that the client’s blood glucose levels are affecting their vision, which can be a sign of poorly managed diabetes or other complications.

Choice E Reason:

I have lost 10 pounds without even trying.

Unintentional weight loss is a concerning symptom of high blood glucose levels. When the body cannot use glucose for energy due to insulin resistance or lack of insulin, it starts to break down muscle and fat for energy, leading to weight loss. This symptom indicates that the client’s diabetes may be uncontrolled, and immediate medical intervention is necessary.

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Correct Answer is B

Explanation

Choice A Reason:

Documenting that the nasogastric tube is in the correct place is not appropriate in this scenario. A gastric pH of 7.35 is too high for stomach contents, which typically have a pH between 1.5 and 3.5. This high pH suggests that the tube may be misplaced, possibly in the respiratory tract or another non-gastric location. Therefore, documenting the tube as correctly placed could lead to serious complications if the tube is indeed misplaced.

Choice B Reason:

Notifying the health care provider is the most appropriate action. A pH of 7.35 is indicative of a potential misplacement of the nasogastric tube. The health care provider needs to be informed immediately to take corrective actions, such as ordering an X-ray to confirm the tube’s placement or re-evaluating the tube’s position. This step is crucial to ensure patient safety and prevent complications such as aspiration pneumonia or other adverse effects.

Choice C Reason:

Checking for placement by auscultating for air injected into the tube is an outdated and unreliable method. This technique can sometimes give false assurance of correct placement, as the sound of air can be heard even if the tube is in the respiratory tract. Current best practices recommend using pH testing and radiographic confirmation for accurate placement verification.

Choice D Reason:

Retesting the pH using another strip might seem like a reasonable step, but it is not the best immediate action. If the initial pH test shows a value of 7.35, it is unlikely that retesting will yield a significantly different result. The priority should be to notify the health care provider to address the potential misplacement promptly.

A. Pink frothy sputum B. Substernal discomfort C. Nail clubbing D. Restlessness E. Cyanosis at nail beds

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

Explanation

Choice A reason: Pink frothy sputum is a classic sign of pulmonary edema, which can occur as a result of oxygen toxicity. When the alveoli in the lungs fill with fluid, it can lead to this type of sputum. This is a critical indicator that the client is experiencing severe respiratory distress and requires immediate medical attention.

Choice B reason: Substernal discomfort or chest pain is another symptom of oxygen toxicity. This discomfort arises due to the irritation and inflammation of the lung tissues caused by high levels of oxygen. It is essential to monitor and address this symptom promptly to prevent further complications.

Choice C reason: Nail clubbing is typically associated with chronic hypoxia and long-term lung diseases, but it is not an acute indicator of oxygen toxicity. Therefore, it is not relevant in this context.

Choice D reason: Restlessness is a common early sign of hypoxia and can also indicate oxygen toxicity. When the brain does not receive adequate oxygen, it can lead to symptoms such as restlessness, confusion, and agitation. This symptom should be taken seriously and addressed immediately.

Choice E reason: Cyanosis at the nail beds indicates a lack of oxygen in the blood, but it is not specific to oxygen toxicity. It can occur in various conditions where there is inadequate oxygenation, such as chronic obstructive pulmonary disease (COPD) or heart failure.

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During a routine medical evaluation, a client is found to have a random blood glucose level of 310 mg/dL. Which client statements are concerning to the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time?

Correct Answer is B

Explanation

A client with chronic lung disease is prescribed 40% oxygen via face mask. Which finding indicates to the nurse that the client is experiencing oxygen toxicity? Select all that apply.

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

Explanation

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