A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed and the pulse and respiratory rate are increased from the client's baseline. The nurse would first take which action?

Assist the RN to prepare an intravenous (IV) insulin infusion.

Give the client 4 oz of orange juice.

Check the client's capillary blood glucose.

Assist the RN to administer 50% dextrose.

Answer and Explanation

The Correct Answer is C

Choice A Reason: Assisting the RN to prepare an IV insulin infusion is not the first action that the nurse should take, as it may not be appropriate for the client's condition without knowing the blood glucose level.

Choice B Reason: Giving the client 4 oz of orange juice is not the first action that the nurse should take, as it may worsen the client's condition if the blood glucose level is high.

Choice C Reason: Checking the client's capillary blood glucose is the first action that the nurse should take, as it helps to determine if the client has hyperglycemia or hypoglycemia and guides the appropriate intervention.

Choice D Reason: Assisting the RN to administer 50% dextrose is not the first action that the nurse should take, as it may be harmful for the client if the blood glucose level is high.

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Correct Answer is B

Explanation

Choice A Reason: Swollen, painful joints are not a sign of Lyme disease in the early stage, but they may occur in the late stage, which can take months or years to develop.

Choice B Reason: An expanding circular rash, also known as erythema migrans, is a sign of Lyme disease in the early stage, which usually appears within 3 to 30 days after the tick bite. The rash may have a bull's-eye appearance and can spread up to 12 inches in diameter.

Choice C Reason: Decreased level of consciousness is not a sign of Lyme disease, but it may indicate other serious conditions such as meningitis, encephalitis, or stroke.

Choice D Reason: Necrosis at the site of the bite is not a sign of Lyme disease, but it may indicate a brown recluse spider bite, which can cause tissue damage and ulceration.

A. Tell the client to expect a decrease in urine output. B. Encourage the client to drink 3 L of fluids per day. C. Provide the client with a high protein diet. D. Maintain the client on bed rest.

Correct Answer is B

Explanation

Choice A Reason: Telling the client to expect a decrease in urine output is not an appropriate intervention for a client who has urolithiasis, as it may indicate dehydration, obstruction, or infection.

Choice B Reason: Encouraging the client to drink 3 L of fluids per day is an appropriate intervention for a client who has urolithiasis, as it helps to flush out stones, prevent new stone formation, and reduce urinary concentration.

Choice C Reason: Providing the client with a high protein diet is not an appropriate intervention for a client who has urolithiasis, as it may increase uric acid and calcium excretion and promote stone formation.

Choice D Reason: Maintaining the client on bed rest is not an appropriate intervention for a client who has urolithiasis, as it may decrease renal perfusion and increase urinary stasis.

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A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed and the pulse and respiratory rate are increased from the client's baseline. The nurse would first take which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed and the pulse and respiratory rate are increased from the client's baseline. The nurse would first take which action?

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