Exhibits

Nursing actions: Indicated/contraindicated/non-urgent

Teach the client how to count carbohydrates

Stop the insulin infusion

Decrease the frequency of blood glucose tests

Start the client on a regular diet

Decrease the insulin IV infusion to 0.05 units/kg/hr

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

A.   Teach the client how to count carbohydrates - Non-urgent. While essential for long- term management of diabetes, carbohydrate counting is not immediately critical in the acute management phase of HHS in the ICU. This teaching should be delayed until the patient is stabilized.
B.   Stop the insulin infusion - Contraindicated. Stopping insulin in a patient with HHS, which is characterized by severe hyperglycemia, would be harmful. Insulin therapy is critical to reduce blood glucose levels safely.

C.   Decrease the frequency of blood glucose tests - Contraindicated. Frequent monitoring is crucial in managing HHS, especially when insulin therapy is being administered, to prevent hypoglycemia and to monitor the effectiveness of treatment.
D.   Start the client on a regular diet - Contraindicated. Introducing a regular diet during the acute phase of HHS could exacerbate the hyperglycemia. Nutritional needs should be assessed and managed carefully, typically starting with IV fluids and gradually transitioning to enteral or oral feeding as the patient stabilizes.
E.   Decrease the insulin IV infusion to 0.05 units/kg/hr- Indicated. As blood sugar levels decrease, the insulin infusion rate may be cautiously reduced to prevent hypoglycemia.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["22"]

Explanation

To calculate the drip rate for an IV, you can use the formula: (Volume to be infused (mL) x Drop factor (gtt/mL)) / Time (min). For the prescribed 1 unit of PRBC at 350 mL to be infused over 4 hours with a drop factor of 15 gtt/mL, the calculation would be: (350 mL x 15 gtt/mL) / (4 hours x 60 minutes/hour). This simplifies to (5250 gtt) / (240 min), which equals 21.875 gtt/min. When rounded to the nearest whole number, the nurse should regulate the infusion to 22 gtt/min.

A. Monitor the amount of drainage from the client's incision. B. Observe both lower extremities for redness and swelling. C. Evaluate the client's ability to use an incentive spirometer. D. Palpate all peripheral pulse points for volume and strength.

Correct Answer is B

Explanation

A. Monitoring incision drainage is important for infection and wound healing but not directly related to the effectiveness of compression devices.
B. Observing both lower extremities for redness and swelling directly assesses the effectiveness of the pneumatic compression devices in preventing deep vein thrombosis (DVT).
C. Evaluating the use of an incentive spirometer is important for respiratory function but unrelated to the compression devices.
D. Palpating peripheral pulse points is useful for circulation assessment but does not specifically evaluate the prevention of DVT, which is the primary purpose of the compression devices.

View Question and Answer

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Exhibits Nursing actions: Indicated/contraindicated/non-urgent

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes 1 unit (350 mL) of packed red blood cells (PRBC) to infuse over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter the numeric value only. Round to the nearest whole number.)

Correct Answer is ["22"]

Explanation

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Correct Answer is B

Explanation

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?

A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called for another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take?

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

Patient Data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Exhibits

Nursing actions: Indicated/contraindicated/non-urgent