The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?

Hard, painless nodule over metatarsophalangeal joint of first toe.

Erythema and edema at the base of the left great toe.

Decreased response to pain discrimination on dorsal surface of foot.

Painful corns and calluses over hammer toes on both feet.

Answer and Explanation

The Correct Answer is B

A. A hard, painless nodule may indicate a deformity but is not an emergency.

B.   Erythema and edema at the base of the left great toe could indicate an infection, such as cellulitis, which requires immediate intervention to prevent complications.
C.   Decreased response to pain discrimination suggests neuropathy, which is concerning but not immediately life-threatening.
D.   Painful corns and calluses are chronic issues that need management but are not urgent.

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Correct Answer is B

Explanation

A. While the length of exposure can be relevant, it is not the most critical factor before starting isoniazid.
B. Isoniazid can cause hepatotoxicity, so a current diagnosis of hepatitis B is crucial to note as it increases the risk of liver damage.
C. A history of intravenous drug abuse is important for overall health assessment but is less critical than current liver disease.
D. Conversion of the PPD test indicates TB exposure, but assessing liver function and potential for hepatotoxicity is more urgent before starting the medication.

A. Chesty B. Start oxygen 3 L via nasal cannula C. Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3") D. Normal saline 150 mi/hour E. NPO F. Start a IV G. Sputum culture H. Place the client on a cardiorespiratory monitor

Correct Answer is ["B","H"]

Explanation

A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.

B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.

E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.

H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.

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The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Correct Answer is B

Explanation

What 2 orders should the nurse complete first?

Correct Answer is ["B","H"]

Explanation

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The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?