A client undergoing screening for diabetes has a fasting plasma glucose level of 118 mg/dL. What should the nurse plan to educate the client about?

Changes to achieve low HDL and high LDL levels.

Self-monitoring of blood glucose.

Maintenance of a healthy weight.

Utilizing carbohydrate counting to match insulin intake.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Changes to achieve low HDL and high LDL levels are not recommended. In fact, the opposite is desired. High levels of HDL (good cholesterol) and low levels of LDL (bad cholesterol) are beneficial for overall health and can help prevent cardiovascular complications associated with diabetes.

Choice B rationale

Self-monitoring of blood glucose is important for managing diabetes, but a fasting plasma glucose level of 118 mg/dL does not necessarily indicate the need for regular self-monitoring. This level is slightly elevated and may indicate prediabetes, but further testing would be needed for a definitive diagnosis.

Choice C rationale

Maintenance of a healthy weight is beneficial for everyone, but it’s particularly important for individuals with prediabetes or diabetes. Achieving and maintaining a healthy weight can help regulate blood glucose levels and prevent or delay the progression of prediabetes to diabetes.

Choice D rationale

Utilizing carbohydrate counting to match insulin intake is a strategy used in the management of diabetes. However, a fasting plasma glucose level of 118 mg/dL, while slightly elevated, does not necessarily indicate the need for insulin therapy or carbohydrate counting. Further testing would be needed to confirm a diagnosis of diabetes.

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Correct Answer is A

Explanation

Choice A rationale

The client diagnosed with peripheral arterial disease has impaired tissue integrity related to ischemic tissue of the legs and feet. This condition is often caused by factors such as physical trauma, thermal factors, chemical injury, infection, nutritional imbalances, fluid imbalances, and altered circulation. The most appropriate outcome to include in the care plan would be for the client to verbalize an understanding of appropriate foot care measures by discharge. This is because maintaining skin integrity and providing effective wound care are crucial aspects of managing this condition. By understanding and implementing appropriate foot care measures, the client can help prevent further tissue damage, promote healing, and improve their overall quality of life.

Choice B rationale

While taking anti-platelet medications can be an important part of managing peripheral arterial disease, it may not directly address the nursing problem of impaired tissue integrity. Anti-platelet medications can help prevent blood clots and improve blood flow, but they do not directly promote wound healing or tissue regeneration.

Choice C rationale

Discussing exercises that promote healing of wounds can be beneficial for the client. However, it’s important to note that exercises should be appropriate for the client’s condition and overall health status. Overexertion or inappropriate exercises could potentially exacerbate the condition and further impair tissue integrity.

Choice D rationale

Recognizing the need for an amputation in the near future can be a realistic outcome for some clients with severe peripheral arterial disease. However, this is typically considered a last resort when all other treatment options have failed. It’s also a drastic measure that can significantly impact the client’s quality of life.

A. Hold the warfarin until the next day’s dose and notify the laboratory. B. Administer the daily dose of warfarin and notify the healthcare provider so tomorrow’s dose can be adjusted. C. Administer the daily dose of warfarin as these are the expected side effects of the medication. D. Hold the warfarin until the healthcare provider is notified of the assessment findings.

Correct Answer is D

Explanation

Choice A rationale

While holding the warfarin and notifying the laboratory could be appropriate actions in some situations, they would not address the immediate concern of the large, new ecchymotic areas on the client’s extremities.

Choice B rationale

Administering the daily dose of warfarin and notifying the healthcare provider for a dose adjustment the next day could potentially exacerbate the bleeding risk, given the presence of the large, new ecchymotic areas.

Choice C rationale

Large, new ecchymotic areas are not expected side effects of warfarin. They could indicate a serious problem such as excessive anticoagulation.

Choice D rationale

The presence of large, new ecchymotic areas could indicate excessive anticoagulation, which is a serious complication of warfarin therapy. Therefore, holding the warfarin and notifying the healthcare provider of the assessment findings would be the most appropriate initial action.

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A client undergoing screening for diabetes has a fasting plasma glucose level of 118 mg/dL. What should the nurse plan to educate the client about?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with peripheral arterial disease has the nursing problem of Impaired Tissue Integrity related to ischemic tissue of the legs and feet. What is an expected outcome to include in the care plan?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is preparing to administer a client’s warfarin sodium 5 mg PO at 1900. Upon entering the client’s room, the nurse finds several large, new ecchymotic areas on the client’s extremities. What should be the nurse’s initial action?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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