The nurse has reviewed the nurses' notes at 0940, vital signs at 0945, and laboratory reports at 1020.

For each assessment finding, click to specify if the finding is consistent with diabetes, pancreatitis, or hyperthyroidism. Each finding may support more than one disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Weight

Heart rate

T3 level

Blood glucose

Answer and Explanation

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

Diabetes:
• Weight
• Blood glucose

Pancreatitis:
• None

Hyperthyroidism:
• Heart rate
• T3 level

Rationale:

• Weight: The client has experienced unintended weight loss, which is a common symptom of diabetes due to the body's inability to use glucose effectively, leading to fat and muscle breakdown.

• Heart rate: Tachycardia is a hallmark of hyperthyroidism due to increased metabolic activity and sympathetic nervous system stimulation.

• T3 level: The T3 level is within the normal range but on the higher end, which can still support hyperthyroidism when considered with other clinical findings.

• Blood glucose: An elevated blood glucose level of 250 mg/dL is consistent with diabetes, as normal fasting levels are below 106 mg/dL.

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Correct Answer is B

Explanation

A. Hypoactive bowel sounds: Hyperkalemia typically causes increased gastrointestinal motility, leading to hyperactive bowel sounds and diarrhea rather than hypoactive bowel sounds.

B. Sinus rhythm with peaked T waves: Elevated potassium levels affect cardiac conduction, leading to ECG changes such as peaked T waves, prolonged PR intervals, and widened QRS complexes. These findings indicate early hyperkalemia and require immediate attention.

C. Irritability and anxiety: While hyperkalemia can cause neuromuscular symptoms, such as muscle weakness and paresthesia, irritability and anxiety are more commonly associated with hypoglycemia or hypoxia rather than hyperkalemia.

D. Shallow respirations: Severe hyperkalemia can lead to muscle weakness, including respiratory muscles, but this occurs in later stages. Shallow respirations are more commonly associated with conditions like respiratory depression or metabolic alkalosis.

A. Drink 3 L of fluids daily. B. Take a warm bubble bath daily. C. Drink low-fructose cranberry juice. D. Void every 6 hr during the day. E. Wipe the perineal area from front to back after urinating.

Correct Answer is ["A","C","E"]

Explanation

A. Drink 3 L of fluids daily: Increasing fluid intake helps flush bacteria from the urinary tract and dilutes urine, reducing the risk of infection. Adequate hydration also promotes more frequent urination, which prevents bacterial colonization in the bladder.

B. Take a warm bubble bath daily: Bubble baths can introduce irritants and disrupt the normal vaginal flora, increasing the risk of urinary tract infections. Soaking in bathwater containing soap or fragrances can also promote bacterial growth and irritation of the urethra.

C. Drink low-fructose cranberry juice: Cranberry juice contains compounds that help prevent bacteria, particularly Escherichia coli, from adhering to the bladder wall. Low-fructose options are preferred to minimize excessive sugar intake, which can contribute to bacterial growth.

D. Void every 6 hr during the day: Holding urine for long periods allows bacteria to multiply in the bladder, increasing the risk of infection. Voiding every 2 to 4 hours is recommended to promote bladder emptying and reduce bacterial colonization.

E. Wipe the perineal area from front to back after urinating: Wiping from front to back prevents the transfer of bacteria from the anal region to the urethra. This simple hygiene practice helps reduce the risk of E. coli contamination, a leading cause of urinary tract infections.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving potassium chloride 40 mEq IV every 4 hr. Which of the following findings indicate the client is becoming hyperkalemic?

Correct Answer is B

Explanation

A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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