A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing:

Type 1 diabetes

Actions to Take:

Teach the client about the signs of hyperglycemia.
Assess the client’s feet for sensation.

Parameters to Monitor:

Fingerstick blood glucose
Blood pressure

Rationale: The client has a high HbA1c (8.4%) and elevated blood glucose level (235 mg/dL), indicating poor blood glucose control. Symptoms such as fatigue, blurred vision, and dizziness suggest hyperglycemia, which can occur in clients with diabetes who have not been able to maintain regular glucose monitoring or insulin administration due to financial constraints. Teaching the client about hyperglycemia symptoms and checking feet for sensation is important due to the risk of complications like neuropathy. Monitoring blood glucose and blood pressure is essential for evaluating diabetes management and preventing complications.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. While sugar can raise blood glucose, it’s often not the most practical or readily available option in a clinical setting.
B. Graham crackers can be useful for longer-term glucose control but might not act as quickly as a liquid option.
C. Diet soda does not contain sugar and will not raise blood glucose levels.
D. Skim milk provides carbohydrates that are quickly absorbed, making it an effective choice for treating mild hypoglycemia.

A. Omit the KCL dose and document that it was not given. B. Give the ordered KCL as prescribed. C. Hold the prescribed dose and notify the provider of the serum potassium level. D. Call the lab to verify the client's results.

Correct Answer is B

Explanation

A. Omitting the KCL dose would be inappropriate, as the client's potassium level is low and requires correction.
B. A potassium level of 3.0 mEq/L is below the normal range (3.5-5.0 mEq/L), and administering the prescribed potassium supplement is appropriate to prevent symptoms of hypokalemia.
C. There is no need to hold the dose and notify the provider, as the KCL is prescribed to correct low potassium levels.
D. The lab results do not need to be verified unless there is suspicion of error, as 3.0 mEq/L is consistent with hypokalemia requiring treatment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 65 mg/dL on the glucometer, he should give the client which of the following?

Correct Answer is D

Explanation

A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.0 mEq/L. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing to administer aspirin 650 mg PO every 12 hr. The amount available is aspirin 325 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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