A nurse is caring for a client in the emergency department.

Exhibits
For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.
Assessment Findings: DKA /HHS

Skin turgor

Urine ketones

Blood pH greater than expected reference range

Blood glucose greater than expected reference range

Creatinine greater than expected reference range

Answer and Explanation

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

A)   Slight tenting of the skin indicates dehydration, which is consistent with both DKA and HHS.
B)   The presence of ketones in the urine is a hallmark of DKA, as it indicates the body is using fat for energy due to a lack of insulin.
C)   A pH of 7.30 is lower than the normal range, suggesting acidosis, which is characteristic of DKA.
D)   A blood glucose level of 468 mg/dL is significantly higher than the normal range, which is a common finding in both DKA and HHS.
E)   An elevated creatinine level indicates kidney dysfunction, which can be a result of dehydration seen in both DKA and HHS.

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Correct Answer is B

Explanation

A. Changing dressings is important but not the priority over assessing cardiac status in an electrical shock injury.
B. Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be immediate and life-threatening consequences of electrical shock injuries.
C. Administering pain medication can be done once the client's cardiac status has been evaluated and stabilized.
D. While maintaining adequate urine output is important, assessing cardiac status takes precedence.

A. A client who has peritonitis reports generalized abdominal pain. B. A client who has pancreatitis reports pain in the left shoulder. C. A client who has angina reports substernal chest pain. D. A client who is postoperative reports incisional pain.

Correct Answer is B

Explanation

A) Generalized abdominal pain reported by a client with peritonitis indicates visceral pain.
B) Pain in the left shoulder reported by a client with pancreatitis is an example of referred pain, as it occurs at a site distant from the actual pathology.
C) Substernal chest pain reported by a client with angina indicates cardiac pain, not referred pain.
D) Incisional pain reported by a postoperative client is localized and does not indicate referred pain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

Correct Answer is B

Explanation

A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?

A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?

A nurse is reviewing the client’s medical record Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Potential Prescription: Anticipated Nonessential Contraindicated

A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse. "I am afraid to have this procedure." Which of the following responses should the nurse make?

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?