A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?

Absence of Chvostek's sign

Presence of Kussmaul respirations

Presence of diaphoresis

Absence of urinary ketones

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Absence of Chvostek's sign is a wrong indication. Chvostek's sign is a twitching of facial muscles in response to tapping the facial nerve and is typically associated with low blood calcium levels (hypocalcemia). It's not directly related to hyperglycemia or high blood sugar levels. Hyperglycemia refers to high blood sugar levels, commonly associated with diabetes mellitus.
Choice B Reason:
Presence of Kussmaul respirations is a right indication. Kussmaul respirations are deep, rapid, and labored breathing patterns often seen in individuals with diabetic ketoacidosis (DKA), a severe complication of diabetes characterized by significantly high blood sugar levels and the presence of ketones in the blood and urine. This type of breathing pattern is the body's attempt to compensate for the acidic state caused by high blood sugar and the buildup of ketones.
Choice C Reason:
Presence of diaphoresis is a wrong indication. Diaphoresis refers to excessive sweating, which can occur due to various reasons such as physical activity, heat, stress, or certain medical conditions. While hyperglycemia can cause symptoms like increased thirst and frequent urination, diaphoresis alone is not a specific indicator of high blood sugar levels.
Choice D Reason:
Absence of urinary ketones is a wrong indication. The presence of urinary ketones indicates the body is breaking down fat for energy, which commonly occurs during periods of insufficient insulin (such as in hyperglycemia or diabetic ketoacidosis). However, the absence of urinary ketones doesn't necessarily rule out hyperglycemia. It's possible for hyperglycemia to be present without ketones in the urine, especially in the early stages or when the body is still managing blood sugar levels without significant ketone production.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason:

LDL (Low-Density Lipoprotein) is incorrect. This is a type of cholesterol and is not specifically monitored in relation to warfarin therapy.

Choice B Reason:

INR (International Normalized Ratio) is correct. Warfarin is an anticoagulant medication, and its dosage needs to be adjusted based on the INR levels. INR monitoring helps assess the clotting tendency of the blood and ensures that the dosage of warfarin is within the therapeutic range to prevent blood clots without causing excessive bleeding.

Choice C Reason:

BUN (Blood Urea Nitrogen) is incorrect. This value is primarily used to assess kidney function and is not directly related to monitoring warfarin therapy.

Choice D Reason:

Hct (Hematocrit) is incorrect. This measures the percentage of red blood cells in the blood and is not directly related to monitoring warfarin therapy for atrial fibrillation.

A. Use a fire extinguisher at the source of the smoke. B. Close the doors to the room and to the bathroom. C. Activate the fire alarm system. D. Assist the client to a nearby common area.

Correct Answer is D

Explanation

Choice A Reason:
Using a fire extinguisher at the source of the smoke is not appropriate. While using a fire extinguisher could potentially help contain a small fire, it's crucial to prioritize rescuing those in immediate danger and alerting others about the fire first by activating the fire alarm. This action ensures that help is on the way and that everyone is aware of the emergency.
Choice B Reason:
Closing the doors to the room and to the bathroom is not appropriate. Closing doors can help contain smoke and fire to some extent, but again, the priority in an emergency situation like this is to rescue those in immediate danger then activate the fire alarm to ensure a swift response and alert others.
Choice C Reason:
Activate the fire alarm system is appropriate. Activating the fire alarm alerts others in the facility and initiates the emergency response protocol, helping to ensure that help is on the way while potentially preventing the spread of fire. However, this step should be taken after assisting the client to safety as they are in immediate danger.
Choice D Reason:
Assisting the client who is in immediate danger to a nearby common area should be the furst step that the nurse takes before alerting other people of the fire. (RACE protocol)

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?

Correct Answer is B

Explanation

A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has gastroesophageal reflux (GERD). Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reviewing a client's medical history to identify risk factors for osteoporosis. The nurse should identify that which of the following findings is a risk factor for developing steps

A home health nurse is reinforcing teaching with an older adult client about safety precautions to take in the home. Which of the following instructions should the nurse include?

A nurse is providing first aid for a client who has a minor burn on one hand, which of the following actions should the nurse take? (Select all that apply.)

A nurse is reinforcing teaching with the partner of a client who has contact precautions in place for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements by the client's partner indicates an understanding of the teaching?

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching?