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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Asking the client to describe the pain allows for a detailed assessment of the pain's quality, location, intensity, and any aggravating or alleviating factors. This information is crucial for tailoring pain management strategies to the client's specific needs.
B. Identifying effective pain relief measures is important but comes after understanding the pain's characteristics.
C. Observing body language and movement can provide clues about pain but is subjective and less accurate than direct communication.
D. A numeric pain scale measures pain intensity but does not provide information about the quality or nature of the pain.
Correct Answer is ["9"]
Explanation
To calculate the new infusion rate in mL/hour for a prescription of 900 units/hour, one must first determine the concentration of the Heparin Sodium solution. The original concentration is 25,000 units in 250 mL, which means there are 100 units per mL. To deliver 900 units/hour, the nurse should program the infusion pump to deliver 9 mL/hour. This is because 900 units divided by the concentration of 100 units/mL equals 9 mL.
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