A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?

"Aren't you interested in learning how to perform this test?"

"Let's talk about what forethinking."

"I'll discuss this with your partner instead."

"Is this something you think you can do?"

Answer and Explanation

The Correct Answer is B

Choice A Reason:

"Aren't you interested in learning how to perform this test?" is incorrect. This response might come across as accusatory or judgmental, potentially making the client feel uncomfortable or defensive, further hindering communication.

Choice B Reason:

"Let's talk about what you're thinking." Is correct. This response acknowledges the client's distraction and aims to understand and address their thoughts or concerns that might be hindering their focus. It invites the client to express any worries or questions they might have, allowing the nurse to provide reassurance or clarification.

Choice C Reason:

"I'll discuss this with your partner instead." Is incorrect. Redirecting the conversation to the client's partner without understanding the client's concerns directly could undermine the client's autonomy and miss the opportunity to address their needs.

Choice D Reason:

"Is this something you think you can do?" is incorrect. While this question aims to assess the client's confidence, it might not effectively address the underlying reason for the client's distraction or encourage open communication about their concerns.

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Correct Answer is D

Explanation

Choice A Reason:

Hyperkalemia is incorrect. Vomiting and diarrhea typically lead to a loss of potassium rather than an increase. These conditions often result in depletion of electrolytes, including potassium, due to the loss of fluids.

Choice B Reason:

Hypocalcemia is correct. While prolonged or severe diarrhea could potentially lead to some electrolyte imbalances, hypocalcemia is not typically a primary finding associated with vomiting and diarrhea. Calcium levels may not be significantly affected by these symptoms compared to sodium and potassium.

Choice C Reason:

Hypermagnesemia is incorrect. Similar to calcium, magnesium levels are not usually significantly impacted by vomiting and diarrhea alone. Hypermagnesemia is more commonly associated with excessive intake of magnesium-containing medications or renal dysfunction rather than acute gastrointestinal symptoms.

In a client experiencing vomiting and diarrhea, the loss of fluids and electrolytes due to these symptoms commonly leads to:

Choice D Reason:

Hyponatremia is correct. Vomiting and diarrhea can cause a loss of sodium and water, leading to decreased sodium levels in the blood, which manifests as hyponatremia. This electrolyte imbalance is a typical finding in individuals experiencing gastrointestinal issues with fluid loss.

A. Apply clean gloves. B. Ask the client to take a deep breath. C. Instill 50 mL of air into the tube. D. Pinch and withdraw the tube. E. Disconnect the tube from the suction device.

Correct Answer is E,C,B,D,A

Explanation

E. Disconnect the tube from the suction device:

Before starting the removal process, it's essential to disconnect the tube from any suction to prevent discomfort or injury to the client during removal.

C. Instill 50 mL of air into the tube:

Instilling air into the tube helps clear any residual contents and lubricates the tube, making it easier and more comfortable to remove.

B. Ask the client to take a deep breath:

Instructing the client to take a deep breath helps relax the throat and upper esophageal muscles, making the removal process smoother and potentially less uncomfortable.

D. Pinch and withdraw the tube:

Withdrawing the tube while the client holds their breath aids in a controlled removal, minimizing discomfort or risk of aspiration.

A. Apply clean gloves:

Lastly, applying clean gloves ensures infection control and maintains cleanliness during the removal process, preventing any potential contamination.

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A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is E,C,B,D,A

Explanation

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