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The nurse has reviewed the Provider Prescriptions at 1045.

Exhibits

Which of the following actions should the nurse perform first?

Apply dressing to the foot wound.

Administer regular insulin 4 units subcutaneously x 1 dose.

schedule an appointment with an ophthalmologist.

Consult an outpatient wound care specialist.

Answer and Explanation

The Correct Answer is B

Rationale for Correct Choice

Administer regular insulin 4 units subcutaneously x 1 dose: The client’s blood glucose is significantly elevated at 250 mg/dL and they are showing signs of hyperglycemia (polyuria, weight loss, nausea). Administering insulin addresses an immediate metabolic imbalance and helps prevent complications such as diabetic ketoacidosis.

Rationale for Incorrect Choices

Apply dressing to the foot wound: Although the wound requires care, it is not the most urgent issue. Delaying insulin administration in a hyperglycemic client with systemic symptoms could increase the risk of metabolic crisis. Wound care can follow stabilization.
Schedule an appointment with an ophthalmologist: While ophthalmologic evaluation is essential for clients with diabetes, this is a non-urgent referral and can be scheduled after acute needs like hyperglycemia and wound care are addressed.
Consult an outpatient wound care specialist: Coordinating specialized wound care is important for infection control and healing, but it is not time-sensitive. The priority is addressing the elevated blood glucose level first to stabilize the client's condition.

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Correct Answer is B

Explanation

A. "Restrict your partner's oral fluid intake to 450 mL/day.": Fluid restriction in ESKD should be individualized based on the client’s kidney function and retention. A strict 450 mL/day limit is not universally applicable.

B. "Limit your partner's potassium intake to 60 mEq/L per day.": Potassium intake is typically restricted in ESKD due to the kidneys' reduced ability to excrete it. The appropriate restriction depends on potassium levels, but generally, it’s advised to limit intake to prevent hyperkalemia and related complications.

C. "Help your partner consume foods containing phosphorus.": Phosphorus intake should be restricted in ESKD, as high phosphorus levels can cause complications like bone disease. Consuming phosphorus-rich foods should be avoided to prevent calcium-phosphorus imbalances and calcification.

D. "Encourage foods high in protein for your partner.": Excess protein intake in ESKD can exacerbate kidney function decline and increase waste buildup. Protein intake should be monitored and reduced to minimize the kidneys’ workload and prevent further damage.

A. Frothy sputum B. Bradycardia C. Warm skin D. Jugular vein distention

Correct Answer is A

Explanation

A. Frothy sputum: Frothy sputum, particularly pink or blood-tinged, is a classic sign of pulmonary edema, which is common in left-sided heart failure. The left side of the heart cannot pump blood effectively, leading to fluid accumulation in the lungs and causing this symptom.

B. Bradycardia: In left-sided heart failure, tachycardia (elevated heart rate) is more commonly seen as the heart tries to compensate for decreased cardiac output, not bradycardia (slow heart rate).

C. Warm skin: In left-sided heart failure, the skin may feel cool and clammy due to poor circulation and reduced cardiac output. Warm skin is not a typical finding in this condition.

D. Jugular vein distention: Jugular vein distention is more indicative of right-sided heart failure, where there is a backup of blood in the venous system. Left-sided heart failure primarily causes symptoms related to pulmonary congestion.

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The nurse has reviewed the Provider Prescriptions at 1045. Exhibits Which of the following actions should the nurse perform first?

Nursing Test Bank

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The nurse has reviewed the Provider Prescriptions at 1045.

Exhibits

Which of the following actions should the nurse perform first?