Exhibits
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1400:
Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg/dL (74 to 106 mg/dL)
1400:
Temperature 36.8° C (98.2° F) Pulse rate 84/min Respiratory rate 16/min
Blood pressure 106/76 mm Hg Oxygen saturation 96% on room air
Client urinating 100 mL/hour
Client is tolerating soft diet and oral fluids
Bilateral pedal pulses 2+
Blood glucose 310 mg/dL (74 to 106 mg/dL)
Pulse rate 84/min
Respiratory rate 16/min
Blood pressure 106/76 mm Hg
Oxygen saturation 96% on room air
admitted to the medical-surgical unit at 1200 today
Alert and orientated x4
The Correct Answer is ["A","B","C","D","E","F","G"]
Blood glucose 310 mg/dL (74 to 106 mg/dL)
The initial blood glucose level was 468 mg/dL, indicating severe hyperglycemia, likely due to diabetic ketoacidosis (DKA). The decrease to 310 mg/dL suggests that the insulin therapy is starting to bring the blood glucose levels down towards normal range. This reduction is a positive sign of response to treatment.
Client urinating 100 mL/hour
This indicates improved kidney function compared to the initial presentation where the client reported frequent urination and nausea. Adequate urine output (typically more than 30 mL/hour) is crucial in managing DKA as it signifies improved renal perfusion and clearance of ketones and glucose from the blood.
Client is tolerating soft diet and oral fluids
This indicates improvement in gastrointestinal function and resolution of nausea, which is consistent with the ondansetron administration for nausea control. It also suggests that the client's appetite and overall condition are improving.
Bilateral pedal pulses 2+
Initially, the pulses were 1+, indicating poorer peripheral perfusion. Bilateral pedal pulses becoming 2+ suggest improved circulation, likely due to the correction of acidosis and hydration status with fluid and electrolyte
Blood pressure
The improvement in the blood pressure indicates that the client is out of the dehydration state caused by DKA.
Pulse rate
Resolution of tachycardia is a good indicator of improved hydration status
Respiratory rate
The decrease in respiratory rate is an indicator of improving acidosis and resolution of Kussmaul breathing common in DKA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A A perforated eardrum can lead to conductive hearing loss, where sound waves cannot efficiently travel through the middle ear to the inner ear.
D. Chronic infections of the middle ear (otitis media) can cause damage to the delicate structures of the middle ear, including the ossicles (bones) and the eardrum, leading to conductive hearing loss or, if severe and untreated, sensorineural hearing loss.
E. Loop diuretics such as furosemide can sometimes cause ototoxicity, which means they can damage the inner ear and lead to hearing loss. This is an important consideration for individuals who are prescribed loop diuretics for medical conditions.
B. High birth weight is not typically considered a significant risk factor for hearing loss unless it was associated with other complications that affected the ears during infancy or childhood.
C. Frequent exposure to low-volume noise is not typically associated with an increased risk of hearing loss
Correct Answer is C
Explanation
B. This statement indicates understanding of preventive measures to reduce the risk of transmitting genital herpes to sexual partners. Using condoms, including natural skin (non-latex) condoms, can help reduce the risk of transmission.
A Antiviral medications for genital herpes are typically prescribed to manage outbreaks and reduce symptoms, but the duration can vary depending on the severity of symptoms and recurrence.
b. People with genital herpes should use latex or polyurethane condoms during sexual intercourse, as these are effective at reducing the risk of transmitting the virus. Natural skin condoms (e.g., lambskin condoms) do not provide an effective barrier against the herpes virus because they have tiny pores that can allow the virus to pass through, potentially leading to transmission.
C. These typically heal within 2-4 weeks. While some might take longer, 6 weeks provides a reasonable timeframe for most cases.
D. Antibiotic ointments are not effective against viruses such as herpes simplex virus (HSV). Treatment for genital herpes typically involves antiviral medications
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