The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

Prior to exercising.

Before going to bed.

Immediately after meals.

During acute illness.

Answer and Explanation

The Correct Answer is D

A. Prior to exercising: Testing before exercise is important, especially for clients on insulin, but may not be necessary for all clients depending on their diabetes management and regimen.

B. Before going to bed: This is often recommended for insulin-dependent diabetics to avoid nocturnal hypoglycemia, but it's not universally required for all clients.

C. Immediately after meals: Postprandial glucose testing is useful, especially for gestational diabetes or insulin adjustments, but it is not routinely required for all diabetics.

D. During acute illness: All clients with diabetes should monitor blood glucose more frequently during illness, as stress hormones can cause hyperglycemia or unexpected hypoglycemia.

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

Explanation

A. Monitor ETT markings between 22 and 26 cm at teeth line: While the placement marking on the ETT can be useful for initial placement, it is not the most reliable way to confirm correct positioning. ETT placement should always be verified by clinical assessment rather than relying solely on measurements.

B. Check for capillary refill of 3 seconds or less: Capillary refill is a general indicator of peripheral circulation and does not directly assess whether the ETT is properly placed in the trachea. It is not useful for confirming ETT placement.

C. Auscultate for presence of bilateral breath sounds: This is a key assessment to confirm that the ETT is properly placed. Bilateral breath sounds indicate that air is entering both lungs, suggesting that the tube is correctly positioned in the trachea and not in the esophagus.

D. Obtain a portable chest x-ray to verify ETT location: A chest x-ray is the gold standard for confirming the correct placement of the ETT. It provides an accurate visual confirmation of the tube’s position relative to the carina and the lungs.

E. Assess for symmetrical chest movement: Symmetrical chest movement is another important assessment to confirm proper ETT placement. If the ETT is correctly placed in the trachea, both sides of the chest will rise and fall equally with each breath, indicating effective ventilation.

A. Determine how long the client has been lying prone. B. Measure the client's vital signs. C. Inspect the dressing on the stump. D. Assist the client in turning to a position of comfort.

Correct Answer is A

Explanation

A. Determine how long the client has been lying prone: Prone positioning is used post-amputation to prevent hip flexion contractures. However, prolonged periods in this position can cause discomfort or complications. Knowing the duration helps evaluate if it’s appropriate to reposition or maintain it for therapeutic reasons.

B. Measure the client's vital signs: Vital signs are important in the postoperative period, but this task can be completed after addressing the client’s immediate request and assessing the potential impact of their current positioning on healing and comfort.

C. Inspect the dressing on the stump: Inspecting the stump is crucial for monitoring for infection or bleeding. However, unless there is a concern based on symptoms or reports from the client, it should follow assessment of position and comfort needs.

D. Assist the client in turning to a position of comfort: Turning the client without assessing how long they have been prone could interfere with therapeutic positioning aimed at preventing complications like hip contractures, especially in early postoperative care.

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The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

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

Explanation

Correct Answer is A

Explanation

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