A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test.

Which of the following findings should indicate to the nurse that the client has hyperglycemia?

Thirst.

Confusion.

Shakiness.

Cool skin.

Answer and Explanation

The Correct Answer is A

Thirst is a common symptom of hyperglycemia, or high blood sugar, in clients with diabetes mellitus.
Choice B is wrong because confusion can be a symptom of both hyperglycemia and hypoglycemia (low blood sugar).
Choice C is wrong because shakiness is more commonly associated with hypoglycemia.
Choice D is wrong because cool skin is not a common symptom of hyperglycemia.

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Correct Answer is C

Explanation

If a client expresses confusion or lack of understanding about a medical procedure, the nurse should notify the provider so that they can clarify any misunderstandings and ensure that the client is fully informed before giving their consent.
Choice A is wrong because providing brochures about the procedure may not be sufficient to address the client’s confusion or lack of understanding.
Choice B is wrong because completing an incident report is not an appropriate action in this situation.
Choice D is wrong because it is the provider’s responsibility to ensure that the client fully understands the procedure and gives informed consent.

A. "No changes noted to the wound from previous nursing notes.". B. "New dressing applied as prescribed; no drainage on old dressing.". C. "The wound seems clean and does not appear to be infected.". D. "Client premedicated with MSO4 subq prior to dressing change.".

Correct Answer is B

Explanation

The nurse’s entry “New dressing applied as prescribed; no drainage on old dressing” demonstrates correct documentation because it includes specific details about the wound and the dressing change.
Choice A is wrong because it does not provide specific details about the wound or the dressing change.
Choice C is wrong because it includes subjective language (“seems” and “does not appear”) rather than objective observations.
Choice D is wrong because it only documents medication administration and does not provide any information about the wound or the dressing change.

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A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia?

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A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test.

Which of the following findings should indicate to the nurse that the client has hyperglycemia?