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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. This requires prompt attention but is not immediately life-threatening.

B. This requires attention but does not pose an immediate threat to the client's condition.

C. An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D. Administering oxygen without humidification could lead to mucosal dryness and damage, and should be addressed promptly.

A. Assess the pin sites for signs of infection. B. Administer pain medication at designated intervals around the clock. C. Assess the pulses proximal to the fracture site. D. Remove traction every shift and provide skin care.

Correct Answer is A

Explanation

A. Assessing the pin sites for signs of infection is essential in clients with skeletal traction to detect any early signs of infection, such as redness, swelling, warmth, or purulent drainage. Prompt identification and management of pin site infections can prevent complications.
B. Administering pain medication at designated intervals around the clock helps to ensure adequate pain control and comfort for the client. However, this intervention alone does not specifically address the care needs related to skeletal traction.
C. Assessing the pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this assessment is not directly related to the care of skeletal traction itself.
D. Removing traction every shift is not indicated unless there is a specific reason to do so as ordered by the healthcare provider. Continuous traction is often necessary for proper alignment and stabilization of the fracture. Additionally, providing skin care is important to prevent skin breakdown around the traction device, but removing traction every shift is not part of routine care.

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Exhibits Nursing actions: Indicated/contraindicated/non-urgent

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Correct Answer is D

Explanation

106 A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

Correct Answer is A

Explanation

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

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 with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

While completing an admission assessment for a client with unstable angina, which closed ended questions should the nurse ask about the client's chest pain?

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?

Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

Exhibits

Nursing actions: Indicated/contraindicated/non-urgent