A nurse on a medical unit is admitting a client.
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Nurses' Notes
Day 1, 1600:
Client admitted from provider's clinic reporting shortness of breath, dry hacking cough, dizziness, and "heart racing."
States they are not able to sleep well on their back at night because of difficulty breathing.
Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 130/min, ECG monitor showing sinus tachycardia, S1, auscultated. Lower extremity edema noted, 2+ bilaterally, Radial and pedal pulses 1+ bilaterally.
Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.
Client reports gaining 10 pounds in the past month.
Reports history of type 2 diabetes mellitus and hypertension.
Heart rate 130/min
ECG monitor showing sinus tachycardia
edema
Breathing rapid and shallow. Crackles
gaining 10 pounds in the past month.
The Correct Answer is ["A","B","C","D","E"]
Correct answers:
Nurses Notes Day 1, 1600:
Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 150/min, ECG monitor showing sinus tachycardia, 5, auscultated. Lower extremity edema noted, 2+ bilaterally. Radial and pedal pulses 1 bilaterally. Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.
Client reports gaining "10 pounds in the past month."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Providing the client with a one-week supply of insulin syringes ensures they have the necessary equipment to administer insulin independently at home. This supports the client's independence while managing their diabetes.
B. Incorrect. While home health visits may be appropriate for some clients with diabetes, arranging daily visits may not be necessary for an independent client who is capable of managing their condition on their own.
C. Incorrect. Notifying the family of the client's health status may be appropriate in certain situations, but it is not essential for an independent client who is capable of managing their diabetes independently.
D. Incorrect. While joining a diabetic support group can be beneficial for many individuals with diabetes, it may not be necessary for all clients, especially those who are independent and prefer to manage their condition on their own.
Correct Answer is C
Explanation
A. Accountability refers to the nurse's responsibility to provide safe and competent care, including administering medications accurately and documenting appropriately.
B. Autonomy refers to the client's right to make decisions about their own care, including whether or not to take prescribed medications.
C. Veracity refers to truthfulness and honesty in communication. By providing the client with accurate information about the purpose of the medication, the nurse is demonstrating veracity. D. Justice refers to fairness and equity in the distribution of resources and treatment. While ensuring access to necessary medications is important for justice, it is not directly related to the nurse's communication about the purpose of the medication.
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