A male client is admitted for observation because he is reporting progressively increasing fatigue over the past month and a brief episode of dizziness that occurred today. He has a history of heartburn and indigestion that he self-treats with ibuprofen and antacids. Which assessment finding should the nurse report immediately to the healthcare provider?

Reference Ranges:
Hemoglobin (14 to 18 g/dL (8.7 to 11.2 mmol/L)]
Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]
Gastric pH [1.5 to 3.5]

Hematocrit 42% (0.42 volume fraction).

Hemoglobin 13 g/dL (8.07 mmol/L).

Positive guaiac of stool.

Gastric pH 2.0.

Answer and Explanation

The Correct Answer is C

A. Hematocrit 42% (0.42 volume fraction):
A hematocrit of 42% is within the normal reference range for males (42% to 52%). While it is important to monitor hematocrit levels, this finding alone does not indicate an immediate issue.

B. Hemoglobin 13 g/dL (8.07 mmol/L):
A hemoglobin level of 13 g/dL is slightly below the normal range for males (14 to 18 g/dL). However, it is not critically low and may not require immediate intervention without additional context or symptoms.

C. Positive guaiac of stool:
A positive guaiac test for stool indicates the presence of occult blood in the stool, which could suggest gastrointestinal bleeding. Given the client's history of heartburn, indigestion, and use of ibuprofen (a nonsteroidal anti-inflammatory drug that can cause gastrointestinal bleeding), this finding is concerning and should be reported immediately to the healthcare provider for further evaluation and management.

D. Gastric pH 2.0:
A gastric pH of 2.0 is within the normal range for gastric acid, as the normal pH of gastric acid typically ranges from 1.5 to 3.5. This finding is expected and does not indicate an immediate problem related to the client's symptoms.

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Correct Answer is B

Explanation

A) Assess for hypoglycemia between meals: While monitoring for hypoglycemia is important, insulin lispro, being a rapid-acting insulin, primarily acts around meal times. Hypoglycemia is most likely to occur around the times when insulin lispro is active, which correlates with meal times rather than between meals.

B) Provide meals at the same time this insulin is given: Insulin lispro is a rapid-acting insulin designed to manage blood glucose levels around meal times. Administering insulin lispro immediately before or with meals helps match the insulin peak with the glucose from the meal, minimizing the risk of postprandial hyperglycemia or hypoglycemia.

C) Keep an oral liquid or glucose source available: Keeping a glucose source available is a good practice to quickly address hypoglycemia if it occurs. However, the most critical intervention is ensuring that insulin administration aligns with food intake to manage glucose levels effectively.

D) Check blood glucose levels every six hours: Checking blood glucose levels every six hours might not capture the fluctuations related to insulin lispro's rapid action. More frequent monitoring around meal times is necessary to adjust doses appropriately and prevent hyperglycemia or hypoglycemia.

A. Avoid the consumption of alcohol. B. Report any color changes to urine. C. Take additional doses as needed. D. Stop medication if a rash develops.

Correct Answer is C

Explanation

A. Avoid the consumption of alcohol:
This instruction is appropriate because alcohol can increase the risk of liver damage when taking acetaminophen. Clients should avoid alcohol to prevent potential adverse effects on the liver.

B. Report any color changes to urine:
Acetaminophen can cause changes in urine color, such as darkening, which might indicate liver problems or other issues. Reporting such changes is important for monitoring potential side effects and ensuring timely intervention.

C. Take additional doses as needed:
This statement requires clarification because acetaminophen should be taken according to the prescribed dosage and frequency. Taking additional doses can lead to an overdose and serious liver damage. Clients should follow the recommended dosing guidelines and consult their healthcare provider if additional pain relief is needed.

D. Stop medication if a rash develops:
If a rash develops, it could be a sign of an allergic reaction or other adverse effect. Stopping the medication and seeking medical advice is appropriate to prevent further complications.

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Naxlex Comprehensive Predictor Exams

Which intervention is most important for the nurse to implement for a client with type 2 diabetes mellitus (DM) who is receiving insulin lispro?

Correct Answer is B

Explanation

The nurse is educating a client about acetaminophen. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is C

Explanation

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