After change-of-shift report, which patient will the nurse assess first?
A 68-year-old patient with type 2 diabetes who has peripheral neuropathy and complains of burning foot pain
A 35-year-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL
A 60-year-old patient with hyperosmolar hyperglycemic syndrome with dry oral mucosa and low urine output
A 19-year-old patient with type 1 diabetes who was admitted with possible dawn phenomenon
The Correct Answer is C
Choice A reason: A 68-year-old patient with type 2 diabetes who has peripheral neuropathy and complains of burning foot pain is not the most urgent patient to assess. Peripheral neuropathy is a complication of diabetes that affects the nerves, especially in the feet and legs. It can cause symptoms such as numbness, tingling, burning, or pain. The nurse should assess the patient's foot condition, provide pain relief, and educate the patient on foot care. However, this patient is not in immediate danger, and can wait until the nurse finishes assessing the more critical patient.
Choice B reason: A 35-year-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL is not the most critical patient to assess. Type 1 diabetes is a condition where the pancreas does not produce any insulin, a hormone that helps the cells use glucose for energy. Patients with type 1 diabetes need to take insulin injections or use an insulin pump to control their blood glucose level. A blood glucose reading of 230 mg/dL is above the normal range of 70 to 130 mg/dL before meals, and indicates hyperglycemia (high blood sugar). The nurse should check the patient's insulin dose, monitor the patient's symptoms, and provide education on blood glucose management. However, this patient is not in life-threatening condition, and can wait until the nurse attends to the more serious patient.
Choice C reason: A 60-year-old patient with hyperosmolar hyperglycemic syndrome with dry oral mucosa and low urine output is the most important patient to assess. Hyperosmolar hyperglycemic syndrome (HHS) is a severe complication of diabetes that occurs when the blood glucose level is extremely high, usually above 600 mg/dL. HHS can cause dehydration, electrolyte imbalance, and coma. Dry oral mucosa and low urine output are signs of dehydration, which can lead to shock and organ failure. The nurse should assess the patient's vital signs, blood glucose level, fluid and electrolyte status, and neurological function. The nurse should also administer intravenous fluids, insulin, and electrolytes as prescribed by the health care provider. This patient is in a medical emergency, and needs immediate intervention.
Choice D reason: A 19-year-old patient with type 1 diabetes who was admitted with possible dawn phenomenon is not the most acute patient to assess. Dawn phenomenon is a condition where the blood glucose level rises in the early morning, usually between 2:00 AM and 8:00 AM. This is due to the release of hormones that increase the blood glucose level, such as growth hormone, cortisol, and glucagon. The nurse should review the patient's blood glucose records, adjust the insulin dose or timing, and provide education on how to prevent or manage the dawn phenomenon. However, this patient is not in a critical situation, and can wait until the nurse evaluates the more unstable patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A serum potassium level of 5.6 mEq/L is not a common side effect of furosemide, but of hyperkalemia. Hyperkalemia is a condition where the blood potassium level is too high. It can cause muscle weakness, irregular heartbeat, and cardiac arrest. Furosemide is a loop diuretic that increases the urinary excretion of water, sodium, chloride, and potassium. It can cause hypokalemia, which is a low blood potassium level, not hyperkalemia.
Choice B reason: A serum sodium level of 142 mEq/L is not a common side effect of furosemide, but of normal sodium level. The normal range of serum sodium level is 135 to 145 mEq/L. Sodium is an electrolyte that helps regulate the fluid balance, nerve impulses, and muscle contractions in the body. Furosemide can cause hyponatremia, which is a low blood sodium level, but not a normal sodium level.
Choice C reason: A serum sodium level of 138 mEq/L is also not a common side effect of furosemide, but of normal sodium level. As explained in choice B, the normal range of serum sodium level is 135 to 145 mEq/L. Furosemide can cause hyponatremia, which is a low blood sodium level, but not a normal sodium level.
Choice D reason: A serum potassium level of 2.8 mEq/L is a common side effect of furosemide, and of hypokalemia. Hypokalemia is a condition where the blood potassium level is too low. It can cause muscle cramps, fatigue, weakness, arrhythmias, and paralysis. Furosemide is a loop diuretic that increases the urinary excretion of water, sodium, chloride, and potassium. It can cause hypokalemia, which is a low blood potassium level. The nurse should monitor the client's serum potassium level and signs of hypokalemia, and advise the client to eat potassium-rich foods, such as bananas, oranges, and potatoes. The nurse should also report the lab value to the prescriber, who may adjust the dose of furosemide or prescribe a potassium supplement.
Correct Answer is C
Explanation
Choice A reason: 363 is not the correct answer. This is the daily maintenance fluid requirement for an infant who weighs 3.5 kg, not 16 kg. The formula for calculating the daily maintenance fluid requirement for infants who weigh between 3.5 and 10 kg is 100 mL/kg¹.
Choice B reason: 727 is not the correct answer. This is the daily maintenance fluid requirement for an infant who weighs 10 kg, not 16 kg. The formula for calculating the daily maintenance fluid requirement for infants who weigh between 10 and 20 kg is 1000 mL plus 50 mL for every kg over 10¹.
Choice C reason: 1300 is the correct answer. This is the daily maintenance fluid requirement for an infant who weighs 16 kg. The formula for calculating the daily maintenance fluid requirement for infants who weigh between 10 and 20 kg is 1000 mL plus 50 mL for every kg over 10¹. Therefore, for an infant who weighs 16 kg, the daily maintenance fluid requirement is 1000 mL plus 50 mL times 6, which equals 1300 mL.
Choice D reason: 1600 is not the correct answer. This is the daily maintenance fluid requirement for an infant who weighs 20 kg, not 16 kg. The formula for calculating the daily maintenance fluid requirement for infants who weigh between 10 and 20 kg is 1000 mL plus 50 mL for every kg over 10¹. For infants who weigh more than 20 kg, the formula is 1500 mL plus 20 mL for every kg over 20¹.
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