A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider?
Obtain capillary blood glucose level every 2 hr
Check the neurovascular status of the client's lower extremities every hour
Apply a cold pack to the client's ankle for 30 min every hour
Maintain the affected ankle elevated and immobilized
The Correct Answer is C
- A. Incorrect. Obtaining capillary blood glucose level every 2 hr is appropriate for a client who has type 1 diabetes mellitus, but it does not address the ankle injury.
- B. Incorrect. Checking the neurovascular status of the client's lower extremities every hour is important for a client who has an ankle injury, but it does not require clarification with the provider.
- C. Correct. Applying a cold pack to the client's ankle for 30 min every hour can reduce swelling and inflammation, but it can also impair circulation and increase the risk of tissue damage in a client who has diabetes mellitus. Therefore, the nurse should clarify this prescription with the provider before implementing it.
- D. Incorrect. Maintaining the affected ankle elevated and immobilized can help prevent further injury and promote healing, but it does not require clarification with the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
"I can designate my partner as my health care surrogate."
- A. Correct. Designating a health care surrogate is one of the components of an advance directive, which allows the client to appoint someone who can make medical decisions on their behalf if they are unable to do so themselves.
- B. Incorrect. Age is not a factor that determines the need for an advance directive, as anyone can become incapacitated at any time due to illness or injury.
- C. Incorrect. A lawyer's help is not necessary to draw up an advance directive, as there are standardized forms available that can be filled out by the client and witnessed by two adults. - D. Incorrect. The family cannot alter or override the advance directives of the client unless they have been designated as their health care surrogate or have obtained a court order to do so.
Correct Answer is ["B","C","E"]
Explanation
The correct answer is B, C, and E.
- A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
- B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
- C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
- D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
- E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.
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