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A nurse in a medical clinic is caring for a client.

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurses' Notes

2 weeks ago, 0940:

Client presents to clinic with reports of feeling unwell for the past few weeks. Client states, "I have a sore that won't get better on my right foot." Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot; draining small amount of purulent drainage. Client awake and alert; chest clear to auscultation; heart tones audible with no abnormal heart tones heard. Client reports frequent urination, increased thirst, and recent 4.5 kg (10 lb) weight loss without trying. Client denies pain but reports experiencing nausea. BMI is 27.

Vital Signs

2 weeks ago, 0945:

Temperature 38.3° C (100.9°F)

Heart rate 104/min

Respiratory rate 18/min

Blood pressure 98/74 mm Hg

Oxygen saturation 97% on room air

Laboratory Results

2 weeks ago 1020:

WBC count 9,500/mm3 (5,000 to 10,000/mm3)

Blood glucose 250 mg/dL (74 to 106 mg/dL)

Triiodothyronine (T3) 200 mg/dL (70 to 205 mg/dL)

I have a sore that won't get better on my right foot."

Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot

draining small amount of purulent drainage

frequent urination

increased thirst

recent 4.5 kg (10 lb) weight loss without trying

Temperature 38.3° C (100.9°F)

Heart rate 104/min

Blood pressure 98/74 mm Hg

Blood glucose 250 mg/dL (74 to 106 mg/dL)

Answer and Explanation

The Correct Answer is ["C","D","E","F","G","H","I","J"]

Open wound on right foot with purulent drainage: A non-healing wound with purulent drainage suggests infection, which is a major concern in clients with hyperglycemia. Poor wound healing is common in diabetes due to impaired circulation and immune function.
Frequent urination, increased thirst, and unexplained 4.5 kg (10 lb) weight loss: Classic symptoms of hyperglycemia and possible diabetes mellitus. Polyuria and polydipsia result from osmotic diuresis due to high blood glucose levels, while unexplained weight loss may indicate the body breaking down fat and muscle for energy.
Temperature 38.3° C (100.9° F): Fever indicates a possible systemic infection. In diabetic clients, infections can progress rapidly and lead to complications such as cellulitis, osteomyelitis, or sepsis.
Heart rate 104/min: Tachycardia may be a response to fever, dehydration, or underlying infection. Persistent tachycardia could indicate worsening sepsis or hemodynamic instability.
Blood pressure 98/74 mm Hg: While not critically low, this blood pressure is on the lower end and could indicate early signs of dehydration from polyuria or systemic infection.
Blood glucose 250 mg/dL: Significantly elevated blood glucose suggests poor glycemic control, increasing the risk of infection, delayed wound healing, and diabetic ketoacidosis (DKA) if it continues to rise.:

Respiratory rate 18/min: A normal respiratory rate does not indicate respiratory distress or metabolic compensation.
Oxygen saturation 97% on room air: Oxygenation is within the normal range, suggesting no immediate hypoxia.
WBC count 9,500/mm³: Within the normal range, although an infection may still be present given the fever and purulent wound drainage.
Triiodothyronine (T3) 200 mg/dL: Within normal limits, ruling out thyroid dysfunction as a cause of symptoms.
BMI 27: Slightly overweight but not directly contributing to the acute condition.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Palpate the dorsalis pedis pulse: Assessing distal pulses ensures adequate circulation to the affected extremity. Impaired blood flow can indicate compartment syndrome or vascular compromise, which are serious complications following fracture stabilization. The nurse should also monitor capillary refill, skin temperature, and sensation.

B. Maintain the affected extremity in a dependent position: Keeping the extremity in a dependent position can increase swelling and venous congestion, leading to complications such as compartment syndrome. Elevation is recommended to minimize edema and promote venous return.

C. Wrap sterile gauze on the sharp point of the pins: The pin sites should be left uncovered to allow for proper monitoring of signs of infection or loosening. Instead, pin site care should be performed per facility protocol to reduce infection risk.

D. Adjust the clamps on the fixator frame: Adjusting the external fixator clamps is outside the nurse's scope of practice. Any modifications to the device should be performed by the orthopedic provider to prevent improper alignment and complications.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

The nurse should first address the client's chest pain followed by the client's irregular heart rate.

Rationale:

Chest pain is the priority concern as it indicates an acute coronary event (ST-elevation myocardial infarction, STEMI). Immediate interventions such as oxygen, nitroglycerin, and pain management are required to reduce myocardial oxygen demand and prevent further cardiac damage.

Irregular heart rate must be addressed next, as tachycardia and arrhythmias can increase myocardial workload and worsen ischemia. Monitoring and possible antiarrhythmic interventions may be required to stabilize cardiac function.

Incorrect:

Troponin levels: Elevated troponin confirms myocardial injury but does not require immediate intervention; managing the ongoing ischemia is the priority.

Oxygen saturation: The client's oxygen saturation is 93% on room air, which is adequate. Oxygen therapy is not the first priority unless levels drop further.

Hyperlipidemia: While a cardiovascular risk factor, it is not an acute concern during an MI. Long-term management is necessary but not the immediate priority.

C-reactive protein: Elevated CRP indicates inflammation but does not require urgent intervention in the acute phase of MI.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 6 hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Complete the following sentence by using the lists of options. The nurse should first address the client's ____ followed by the client's ____ .

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

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