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Exhibits

Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.

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

Answer and Explanation

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

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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

D. Naloxone competitively binds to opioid receptors, displacing opioids from these receptors and rapidly reversing their effects. It is the drug of choice for managing opioid-induced respiratory depression and is administered to restore adequate ventilation and prevent respiratory arrest.

A Diphenhydramine is an antihistamine with sedative properties. It is used primarily for allergic reactions and as a sleep aid. Diphenhydramine is not indicated for reversing respiratory depression caused by opioid overdose. It does not antagonize opioid receptors or reverse the effects of opioids.

B. Flumazenil is not effective in reversing respiratory depression caused by opioid overdose. It does not affect opioid receptors or reverse the respiratory depressant effects of opioids.

C. Calcium gluconate is a form of calcium used to treat hypocalcemia or to counteract the cardiac effects of hyperkalemia. It does not reverse opioid-induced respiratory depression. It is not indicated in this situation.

A. Decreased responsiveness of airways to allergens B. Suppressed bronchiolar inflammatory response C. Inability to exhale retained carbon dioxide D. Acute loss of alveolar elasticity

Correct Answer is C

Explanation

C. During an asthma attack, the airways narrow, making it difficult to exhale. This traps air in the lungs, including carbon dioxide.

A This might be true for someone with poorly controlled asthma, but during an acute attack, the airways are already hypersensitive and constricted in response to triggers.

B. This is the opposite of what happens in asthma. Asthma is characterized by inflammation in the airways.

D. Alveolar elasticity refers to the ability of the air sacs in the lungs to recoil after being inflated. While this can be a problem in some lung diseases, it's not the primary issue in an acute asthma attack.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative and develops respiratory depression after receiving morphine for pain control. Which of the following medications should the nurse expect the provider to prescribe?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?

Correct Answer is C

Explanation

A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?

A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?

A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following responses should the nurse make?

A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?

A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?

A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?

Exhibits Which of the following actions should the nurse take? For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.