A nurse is caring for a client who is being admitted to t

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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 []

Potential Condition: The client’s elevated HbA1c (8.4%) and blood glucose level (235 mg/dL) indicate poorly controlled diabetes mellitus, which is likely leading to their symptoms of fatigue, blurred vision, dizziness, and headache. The client’s history of running out of insulin and glucose strips further supports the diagnosis of Type 1 diabetes mellitus, or possibly poorly controlled Type 2 diabetes mellitus.

Actions to Take:

Teach the client about the signs of hyperglycemia: Given the elevated blood glucose levels and lack of regular monitoring, it is essential to educate the client on recognizing signs of hyperglycemia to prevent complications such as diabetic ketoacidosis.

Assess the client’s feet for sensation: Diabetes can lead to neuropathy, increasing the risk of foot injuries and infections. Regular assessment of foot sensation is vital for early detection and prevention of complications.

Parameters to Monitor:

Fingerstick blood glucose: Frequent monitoring of blood glucose is necessary to assess the effectiveness of the insulin regimen and to make necessary adjustments.

Urinary output: Monitoring urinary output is important because polyuria is a common symptom of hyperglycemia. Decreased urine output may also indicate dehydration or renal impairment, both of which are complications of poorly controlled diabetes.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Levofloxacin is an antibiotic used to treat bacterial infections, not hypothyroidism.

B. Radioactive iodine is used to treat hyperthyroidism by reducing thyroid hormone production, not hypothyroidism.

C. Sumatriptan is a medication used to treat migraines, not hypothyroidism.

D. Levothyroxine is the standard treatment for hypothyroidism. It is a synthetic form of the thyroid hormone thyroxine (T4) and helps to normalize thyroid function by supplementing the hormone that the thyroid gland is not producing adequately

A. Adjust the rate of the bladder irrigation. B. Ambulate the client. C. Notify the provider. D. Check the tubing for kinks.

Correct Answer is D

Explanation

A. Adjusting the rate of the bladder irrigation might be necessary, but it is not the first action to take when there is no drainage.

B. Ambulating the client can help promote bladder function, but it is not the immediate priority when assessing catheter function.

C. Notifying the provider is important if the issue cannot be resolved, but the nurse should first attempt to resolve common, simple issues like a kinked tube.

D. Checking the tubing for kinks is the most immediate and logical first action to take. Kinks in the tubing can obstruct urine flow, and correcting this can often resolve the issue without further intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new diagnosis of hypothyroidism. On which of the following medications should the nurse prepare to instruct the client?

Correct Answer is D

Explanation

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)

A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching?

A nurse is preparing a teaching session about reducing the risk of complications of diabetes mellitus. Which of the following information should the nurse plan to include in the teaching? (Select all that apply.)

A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity?

A nurse is teaching a client who has diabetes mellitus and a new prescription for glimepiride. The nurse should teach the client to avoid which of the following drinks while taking this medication?

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?