A nurse is assessing a client who has type 1 diabetes. Which of the following manifestations could indicate that the client is hypoglycemic?

Poor skin turgor.

Fruity breath odor.

Kussmaul respirations.

Irritability.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.

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Correct Answer is C

Explanation

Answer: C. "Insert the entire needle into your skin to administer medication completely."

Rationale:

A) "Administer this medication into your leg muscle."
Enoxaparin should be administered subcutaneously, typically in the abdominal area, not into a muscle. Injecting it intramuscularly can lead to unpredictable absorption and increase the risk of bleeding.

B) "Expel the excess air in the syringe before you administer the medication."
This statement is incorrect. For enoxaparin, it is recommended to retain the air bubble in the syringe. The air bubble helps ensure the entire dose is delivered and minimizes leakage at the injection site.

C) "Insert the entire needle into your skin to administer medication completely."
This is an appropriate instruction as it emphasizes the need to fully insert the needle for effective subcutaneous delivery of enoxaparin. Proper technique is essential to ensure the medication is administered as intended.

D) "Take ibuprofen for fever following administration of this medication."
This recommendation is not advisable because ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), can increase the risk of bleeding, especially when taken concurrently with enoxaparin. The client should consult their healthcare provider for safe alternatives for managing fever or pain.

A. Elevated WBC Count. B. Elevated amylase level. C. Rebound tenderness. D. Ascites. E. Anorexia.

Correct Answer is ["A","C","E"]

Explanation

Choice A rationale:

An elevated white blood cell (WBC) count is an expected manifestation in a client with suspected appendicitis. Inflammation in the appendix leads to an immune response, causing an increase in WBC count.

Choice B rationale:

Elevated amylase level is not typically associated with appendicitis. Elevated amylase is more commonly seen in pancreatitis, not appendicitis.

Choice C rationale:

Rebound tenderness, which refers to increased pain when pressure is released rather than applied, is a classic symptom of appendicitis. The nurse should expect to find rebound tenderness during the abdominal assessment.

Choice D rationale:

Ascites are not a common manifestation of appendicitis. Ascites is the accumulation of fluid in the abdominal cavity and are more commonly seen in liver cirrhosis and certain other conditions, but not in appendicitis.

Choice E rationale:

Anorexia, or loss of appetite, can be seen in clients with appendicitis due to the inflammation and discomfort in the abdominal region.

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A nurse is assessing a client who has type 1 diabetes. Which of the following manifestations could indicate that the client is hypoglycemic?

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Naxlex Comprehensive Predictor Exams

A nurse is completing discharge teaching with a client who has a new prescription for enoxaparin to treat unstable angina. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect?(Select all that apply.).

Correct Answer is ["A","C","E"]

Explanation

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