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:

B. Type 1 diabetes mellitus

The client’s symptoms of fatigue, blurred vision, dizziness, and headache, along with a high blood glucose level and HbA1C, suggest that they are experiencing hyperglycemia, a condition common in individuals with Type 1 diabetes mellitus.

Actions to Take:

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

Teaching the client about the signs of hyperglycemia will help them recognize when their blood sugar is high and take appropriate action. Assessing the client’s feet for sensation is also important as diabetes can lead to peripheral neuropathy, which can result in a loss of sensation in the feet.

Parameters to Monitor:

B. Blood pressure
D. Fingerstick blood glucose

Monitoring the client’s blood pressure is important as hypertension can be a complication of diabetes. Regularly checking the client’s fingerstick blood glucose levels will help ensure that their diabetes is being effectively managed.

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Correct Answer is A

Explanation

Choice A rationale

The rubella vaccine is a live vaccine, which means it contains a weakened version of the virus. Because the virus is still active, live vaccines are not safe for pregnant people. There is a small chance they may pass the virus to the baby. Therefore, it is recommended that adults of childbearing age should avoid getting pregnant for at least four weeks after receiving the MMR vaccine. This is to ensure the safety of both the mother and the baby.

Choice B rationale

This statement is incorrect. The rubella vaccine does not require additional shots after each baby with Rh-positive blood. The rubella vaccine is typically administered in childhood and provides long-term protection.

Choice C rationale

This statement is also incorrect. The rubella vaccine does not require additional shots in 1 month and again in 6 months. The vaccine provides long-term protection and does not typically require frequent boosters.

Choice D rationale

While it’s true that some vaccines can cause side effects such as fever and vomiting, these are not common side effects of the rubella vaccine. Therefore, this statement is not entirely accurate.

A. Vitamin K B. Protamine C. Epinephrine D. Vitamin D .

Correct Answer is A

Explanation

Choice A rationale

Vitamin K is used to reverse the effects of warfarin. Warfarin is an anticoagulant that works by inhibiting the synthesis of vitamin K-dependent clotting factors. When the INR is too high, indicating a high risk of bleeding, vitamin K can be administered to increase the production of clotting factors and reduce the risk.

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Naxlex Comprehensive Predictor Exams

A client’s prenatal laboratory findings reveal no immunity to rubella.The health care provider orders the rubella vaccine.The nurse concludes that teaching about this medication is effective when the client states which of the following?

Correct Answer is A

Explanation

A nurse is caring for a client who is on warfarin therapy for atrial fibrillation.The client’s INR is 5.2. Which of the following medications should the nurse prepare to administer?

Correct Answer is A

Explanation

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