A nurse is caring for a 38-year-old client who presents to the emergency department (ED) in pain.

Exhibits

For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Intravenous fluid administration

Ice packs to affected area 15 min on/15 min off

Ambulation in hallway with supervision

Hydromorphone intravenously (IV) for pain

Acetaminophen orally (PO) for pain

Oxygen 2 L/min via nasal cannula

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Intravenous fluid administration is anticipated as hydration can help reduce the viscosity of sickled cells, improving circulation and potentially reducing vaso-occlusive events.

Ice packs to the affected area are nonessential and could potentially be contraindicated, as cold can cause vasoconstriction and may exacerbate pain.

Ambulation is nonessential during acute pain episodes and should be encouraged when the patient is comfortable and pain is controlled.

Hydromorphone IV for pain is anticipated because it is a stronger opioid than morphine and may be necessary if the pain is unresponsive to oral morphine sulfate.

Acetaminophen PO for pain is nonessential in this scenario as it is unlikely to provide adequate pain relief for severe vaso-occlusive pain.

Oxygen therapy is nonessential given the client's SpO2 is 95% on room air, indicating adequate oxygen saturation; however, it may be considered if there is evidence of hypoxia or respiratory distress. It is crucial to monitor the client's response to pain management interventions and adjust the treatment plan accordingly.

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Correct Answer is D

Explanation

A. Anuria, or the absence of urine output, occurs in later stages of shock when there is significant renal hypoperfusion. It is not an early indicator of shock.
B. Hypotension is a classic sign of shock, but it generally occurs after compensatory mechanisms have failed. It is not the earliest indicator.
C. A decreased level of consciousness occurs later in the progression of shock due to decreased cerebral perfusion. It is not the earliest sign of shock.
D. Increased respiratory rate is often the earliest indicator of shock. As the body attempts to compensate for decreased oxygen delivery and tissue perfusion, the respiratory rate increases to enhance oxygenation and eliminate excess carbon dioxide. This compensatory mechanism is typically one of the first signs that shock is developing.

A. "DKA happens when the body's cells can't respond appropriately to the insulin being produced and blood glucose levels rise." B. "DKA is a metabolic disorder generally resulting from getting sick while having diabetes mellitus type 2." C. "DKA can only be acquired in a client with diabetes mellitus type 1 who experiences septic shock." D. "DKA results from the complete absence of insulin resulting from poorly controlled or undiagnosed diabetes mellitus type 1."

Correct Answer is D

Explanation

A. DKA occurs due to a significant deficiency of insulin rather than issues with cell response to insulin. The condition leads to high blood glucose and ketone production because there is not enough insulin to regulate glucose levels effectively.
B. DKA is primarily associated with diabetes mellitus type 1, not type 2. It can occur due to a lack of insulin and is not solely caused by illness, although illness can exacerbate it.
C. DKA is not limited to clients with diabetes mellitus type 1 who experience septic shock. It can occur in anyone with type 1 diabetes due to severe insulin deficiency, though septic shock can complicate the condition.
D. DKA results from a complete absence of insulin, which is characteristic of poorly controlled or undiagnosed diabetes mellitus type 1. This insulin deficiency leads to elevated blood glucose levels and ketone formation.

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A nurse is caring for a 38-year-old client who presents to the emergency department (ED) in pain. Exhibits For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Correct Answer is D

Explanation

A nurse is caring for a client with diabetic ketoacidosis (DKA). The client asks why he has this condition. What is the nurse's best answer?

Correct Answer is D

Explanation

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A nurse is caring for a 72-year-old client who has type 1 diabetes mellitus. Exhibits Select the 3 findings that require immediate follow-up.

A nurse is assessing a client who has diabetes mellitus type 2 and presents for a follow-up visit. Which of the following lab values is most indicative of inadequate control of their diabetes since their last primary care visit and requires further teaching?

A nurse is caring for a 38-year-old client who presents to the emergency department (ED) in pain.

Exhibits

For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.