A nurse is in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?
Report of decreased urinary output
Random blood glucose 126 mg/dL
Clammy skin
History of poor wound healing
The Correct Answer is D
A. Report of decreased urinary output
Explanation: Decreased urinary output is not typically associated with hyperglycemia. In fact, increased urinary output (polyuria) is more characteristic.
B. Random blood glucose 126 mg/dL
Explanation: This level is within the normal range for random blood glucose. Hyperglycemia is usually defined by higher blood glucose levels.
C. Clammy skin
Explanation: Clammy skin is not a direct manifestation of hyperglycemia. Symptoms of hyperglycemia may include increased thirst, frequent urination, and blurred vision.
D. History of poor wound healing
Explanation: This is correct. Hyperglycemia can contribute to impaired wound healing, as it affects the body's ability to repair tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B"]
Explanation
Correct answer: B
A. Check the gastric residual every 8 hr:
Explanation:It is generally recommended to check gastric residuals more frequently than every 8 hours, often every 4-6 hours, especially in the initial stages of continuous enteral feedings, to monitor tolerance and prevent complications such as aspiration.
B. Change the feeding bag every 24 hr:
Explanation: Changing the feeding bag and tubing at regular intervals helps prevent bacterial contamination and maintain aseptic technique. The frequency of bag changes is typically scheduled every 24 hours or according to facility protocols.
C. Flush the tube with sterile sodium chloride solution every 2 hr:
Explanation:While it is important to flush the feeding tube regularly to maintain patency, using sterile water is typically recommended unless there is a specific clinical indication for sterile sodium chloride. The frequency of flushing (usually every 4-6 hours for continuous feeding) should be determined based on the institution's protocol and the client's specific needs.
D. Position the head of the client's bed at 15 degrees:
Explanation:To reduce the risk of aspiration, the head of the bed should be elevated to at least 30-45 degrees during enteral feedings, not just 15 degrees. Elevating the head of the bed helps prevent reflux and aspiration.
Correct Answer is B, A, D, C
Explanation
1. Inject 10 units of air into the regular insulin vial.
Explanation: Similar to the NPH insulin vial, injecting air into the regular insulin vial creates positive pressure, facilitating the withdrawal of the correct dose of regular insulin.
2. Inject 20 units of air into the NPH insulin vial.
Explanation: This step ensures that there is positive pressure in the vial, making it easier to withdraw the desired dose of NPH insulin.
3. Withdraw 10 units of air from the regular insulin vial.
Explanation: Following the injection of air into the regular insulin vial, the nurse withdraws 10 units of regular insulin from the vial.
4. Withdraw 20 units of air from the NPH insulin vial.
Explanation: After injecting air into the NPH insulin vial, the nurse withdraws 20 units of NPH insulin from the vial.
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