A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?

Irritability

Increased urination

Vomiting

Facial flushing

Answer and Explanation

The Correct Answer is A

A. Irritability: Correct. Irritability is one of the signs of hypoglycemia, which occurs when blood glucose levels fall below 70 mg/dL (3.9 mmol/L). Other signs include shakiness, sweating, hunger, headache, confusion, and blurred vision.

B. Increased urination: Incorrect. Increased urination is one of the signs of hyperglycemia, which occurs when blood glucose levels rise above 180 mg/dL (10 mmol/L). Other signs include thirst, dry mouth, fatigue, nausea, and fruity breath odor.

C. Vomiting: Incorrect. Vomiting is not a specific sign of hypoglycemia or hyperglycemia, but it can occur as a complication of either condition if left untreated or poorly managed.

D.Facial flushing: Incorrect. Facial flushing is not a sign of hypoglycemia or hyperglycemia, but it can occur as a side effect of some medications used to treat diabetes, such as niacin or rosiglitazone.

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Correct Answer is A

Explanation

A. Droplet: Correct. Pneumonia is transmitted by respiratory droplets that are generated by coughing, sneezing, or talking. The nurse should wear a surgical mask and eye protection when caring for the client and maintain a distance of at least 3 feet from the client.

B. Airborne: Incorrect. Airborne precautions are used for diseases that are transmitted by small particles that remain suspended in the air for long periods of time, such as tuberculosis, measles, or chickenpox. The nurse should wear a respirator and place the client in a negative-pressure room.

C. Contact: Incorrect. Contact precautions are used for diseases that are transmitted by direct or indirect contact with the client or the client's environment, such as Clostridium difficile, scabies, or MRSA. The nurse should wear gloves and a gown and use dedicated equipment for the client.

D. Protective environment: Incorrect. Protective environment precautions are used for clients who are immunocompromised and at risk of infection from others, such as clients who have had a stem cell transplant or are receiving chemotherapy. The nurse should wear a mask, gloves, and a gown and place the client in a positive-pressure room with HEPA filtration.

A. Initiation of changes in infection control measures B. Increasing the client's dietary servings of fruits and vegetables C. Limiting the client's ﬂuid intake to avoid hemodilution D. Avoiding the client's exposure to cold temperatures

Correct Answer is A

Explanation

Anti-Glycan Neu5Gc Antibodies (AGNA) are antibodies that recognize a carbohydrate antigen called N- glycolylneuraminic acid (Neu5Gc), which is found in animal-derived foods and tissues, but not in humans. Humans can incorporate Neu5Gc from their diet into their own cells, which can trigger an immune response and the production of AGNA.
AGNA have been associated with various inﬂammatory and autoimmune diseases, such as atherosclerosis, rheumatoid arthritis, Crohn's disease, and cancer. AGNA may also play a role in the rejection of bioprosthetic heart valves, which are made from animal tissues that contain Neu5Gc.
A client with carcinoma in situ of the left breast is a client with a non-invasive form of breast cancer, where the abnormal cells are confined to the ducts or lobules of the breast. This type of cancer has a high chance of cure with surgery and/or radiation therapy.
Increased levels of AGNA in a client with carcinoma in situ of the left breast may indicate that the client has an increased risk of inﬂammation and infection, as AGNA can activate the complement system and recruit inﬂammatory cells to the site of Neu5Gc expression. This may impair the healing process and increase the chances of complications after surgery or radiation therapy.

Therefore, the practical nurse (PN) should anticipate that the client's plan of care will include initiation of changes in infection control measures, such as prophylactic antibiotics, wound care, sterile dressing changes, and monitoring for signs and symptoms of infection (such as fever, redness, swelling, pain, or pus). These measures will help to prevent or treat any potential infection and promote wound healing.

Therefore, option A is the correct answer, while options B, C, and D are incorrect.

Option B is incorrect because increasing the client's dietary servings of fruits and vegetables may not have a significant impact on the levels of AGNA or Neu5Gc in the client's body.

Option C is incorrect because limiting the client's ﬂuid intake to avoid hemodilution may not be necessary or beneficial for the client's condition.

Option D is incorrect because avoiding the client's exposure to cold temperatures may not be relevant or helpful for the client's condition.

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A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

Correct Answer is A

Explanation

While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices increased levels of Anti-Glycan Neu5Gc Antibodies (AGNA). Which changes should the PN anticipate to be included in the client's plan of care?

Correct Answer is A

Explanation

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