A client is admitted for treatment of Addison's crisis. Which finding is most important for the practical nurse (PN) to report to the charge nurse? Reference Range: Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L].

The client reports feeling nauseous.

Has not voided in four hours.

IV infusion site is infiltrated

Serum glucose level of 85 mg/dL.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C - IV infusion site is infiltrated. Choice A rationale:

The client reports feeling nauseous. While this symptom should be monitored, it is not the most crucial finding to report for a client in Addison's crisis. Nausea can be a common symptom during various medical conditions and may not warrant immediate action.

Choice B rationale:

Has not voided in four hours. While monitoring urine output is important, it may not be the most critical finding in Addison's crisis. Other symptoms like electrolyte imbalances and

circulatory collapse is more concerning in this scenario.

Choice C rationale:

IV infusion site is infiltrated. In Addison's crisis, the client's condition may be precarious, and any complications with IV therapy could worsen the situation. It is essential to report this finding promptly to prevent further complications.

Choice D rationale:

A serum glucose level of 85 mg/dL. While monitoring glucose levels is essential in many situations, a glucose level of 85 mg/dL is within the reference range, which means it is not the most critical finding in Addison's crisis.

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Correct Answer is B

Explanation

Choice A rationale:

The risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.

Choice B rationale:

Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.

Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.

Choice C rationale:

Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.

Choice D rationale:

Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.

A. Glaucoma B. Macular edema. C. Cataract D. Diabetic retinopathy

Correct Answer is A

Explanation

Glaucoma is a group of eye diseases that damage the optic nerve and cause vision loss. It is often associated with increased intraocular pressure, which can compress the nerve fibers and reduce blood ﬂow to the retina. The most common type of glaucoma, open-angle glaucoma, causes gradual loss of peripheral vision.

The other options are not correct because:

Macular edema is a condition that causes swelling and ﬂuid accumulation in the macula, the central part of the retina that is responsible for sharp and detailed vision. It can cause blurred or distorted vision, but it does not aﬀect the optic nerve or the peripheral vision.
Cataract is a condition that causes clouding of the lens, which is the transparent structure that focuses light onto the retina. It can cause blurred, dim, or yellowed vision, but it does not aﬀect the optic nerve or the intraocular pressure.
Diabetic retinopathy is a complication of diabetes that damages the blood vessels in the retina and causes bleeding, leakage, or scarring. It can cause blurred, ﬂuctuating, or darkened vision, but it does not aﬀect the optic nerve or the intraocular pressure.

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A client is admitted for treatment of Addison's crisis. Which finding is most important for the practical nurse (PN) to report to the charge nurse? Reference Range: Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L].

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a client who has darkened membranes of the mouth and a smoky breath. Which priority nursing problem should the PN include in the plan of care?

Correct Answer is B

Explanation

The practical nurse (PN) is reviewing a client's recent ophthalmic screening test results. Findings of optic neuropathy, loss of peripheral vision, and increased intraocular pressure are consistent with which medical condition?

Correct Answer is A

Explanation

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the PN take?

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