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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Correct Answer is A

Explanation

A. Diarrhea can lead to significant fluid and electrolyte imbalances, especially in older adults. Prioritizing hydration and electrolyte management is essential to prevent severe complications like renal failure or shock.
B. While caregiver stress is significant and must be addressed, it is not as immediately life-threatening as a fluid volume deficit.
C. This is an ongoing management issue but does not pose an immediate threat to the client's life compared to fluid and electrolyte imbalances.
D. Although important for overall care and prevention of complications such as pressure ulcers, it is not as critical as managing fluid volume deficit in this scenario.

A. Find outlets for more social interaction. B. Think about reasons the episodes occur. C. Practice using muscle relaxation techniques. D. Center attention on positive upbeat music.

Correct Answer is C

Explanation

A. Social interaction can help, but it is not the most effective immediate strategy for managing anxiety.
B. Reflecting on the reasons for anxiety is useful for long-term management but not for immediate relief.
C. Muscle relaxation techniques are an effective and immediate method for reducing anxiety symptoms.
D. Listening to music can help but is less effective than targeted relaxation techniques.

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Exhibits Nursing actions: Indicated/contraindicated/non-urgent

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review?

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?

Exhibits Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have a least one but may have more than response option selected

Exhibits What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

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.)

Exhibits

Nursing actions: Indicated/contraindicated/non-urgent