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During a routine medical evaluation, a client is found to have a random blood glucose level of 310 mg/dL. Which client statements are concerning to the nurse? Select all that apply.

I sleep at least 8 hours each night.

I cannot seem to quench my thirst.

I have to void nearly every hour.

At times my vision is blurry.

I have lost 10 pounds without even trying.

Answer and Explanation

Correct Answer : B

Choice A Reason:

I sleep at least 8 hours each night.

This statement is not concerning because getting adequate sleep is generally a sign of good health. It does not directly relate to symptoms of high blood glucose levels. Therefore, this choice is not relevant to the nurse’s concerns regarding the client’s elevated blood glucose level.

Choice B Reason:

I cannot seem to quench my thirst.

This statement is concerning because excessive thirst, known as polydipsia, is a common symptom of high blood glucose levels or hyperglycemia. When blood glucose levels are elevated, the body tries to eliminate the excess glucose through urine, leading to dehydration and increased thirst. This symptom indicates that the client’s blood glucose levels may be poorly controlled, which requires medical attention.

Choice C Reason:

I have to void nearly every hour.

Frequent urination, or polyuria, is another symptom of high blood glucose levels. When there is too much glucose in the blood, the kidneys work harder to filter and absorb it. When they can’t keep up, the excess glucose is excreted into the urine, pulling fluids from the tissues and causing frequent urination. This symptom is a clear indicator of hyperglycemia and needs to be addressed by the nurse.

Choice D Reason:

At times my vision is blurry.

Blurred vision can be a symptom of high blood glucose levels. Elevated glucose levels can cause the lens of the eye to swell, leading to changes in vision. This symptom is concerning because it suggests that the client’s blood glucose levels are affecting their vision, which can be a sign of poorly managed diabetes or other complications.

Choice E Reason:

I have lost 10 pounds without even trying.

Unintentional weight loss is a concerning symptom of high blood glucose levels. When the body cannot use glucose for energy due to insulin resistance or lack of insulin, it starts to break down muscle and fat for energy, leading to weight loss. This symptom indicates that the client’s diabetes may be uncontrolled, and immediate medical intervention is necessary.

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Correct Answer is C

Explanation

Choice A reason:

Strict monitoring of hourly intake and output is important for managing fluid balance and detecting potential complications such as dehydration or fluid overload1. However, it is not the highest priority in the acute phase of bacterial meningitis. The primary concern is to monitor for signs of increased intracranial pressure (ICP) and neurological deterioration.

Choice B reason:

Managing pain through drug and non-drug methods is essential for patient comfort and overall well-being. Pain management can help reduce stress and improve the patient’s ability to rest and recover. However, it is not the highest priority compared to monitoring neurological status, which can provide early indications of complications such as increased ICP or seizures.

Choice C reason:

Assessing neurological status at least every 2 to 4 hours is the highest priority for a client with bacterial meningitis. This frequent assessment helps detect early signs of neurological deterioration, increased ICP, and other complications. Early detection and intervention are crucial in preventing severe outcomes and improving the patient’s prognosis.

Choice D reason:

Decreasing environmental stimuli is important to reduce stress and prevent exacerbation of symptoms such as headache and photophobia. While this intervention is beneficial, it is not as critical as frequent neurological assessments in the acute management of bacterial meningitis.

A. You’ll need to let your doctor know if you have seafood allergies. B. Do not take your scheduled dose of Metformin 500 mg PO. C. The procedure will be done at the bedside. D. Take your Metformin as usual before the test.

Correct Answer is B

Explanation

Title: Choice A Reason:

Patients with seafood allergies may have a higher risk of allergic reactions to iodinated contrast media used in CT scans. However, this is not a definitive contraindication. The nurse should inform the patient to notify their healthcare provider about any known allergies, including seafood, as a precautionary measure. This allows the healthcare team to take necessary steps to prevent any adverse reactions, such as premedication with antihistamines or corticosteroids.

Title: Choice B Reason:

Metformin is a common medication used to manage type II diabetes. When a patient is scheduled for a CT scan with IV contrast, it is crucial to withhold Metformin before the procedure. This is because the combination of Metformin and iodinated contrast can increase the risk of contrast-induced nephropathy (CIN) and lactic acidosis, a rare but serious condition. The general recommendation is to stop Metformin at the time of or prior to the procedure and withhold it for 48 hours after the procedure, resuming only after renal function has been re-evaluated and found to be normal.

Title: Choice C Reason:

CT scans, especially those requiring IV contrast, are typically performed in a radiology suite equipped with the necessary technology and medical personnel. Performing such a procedure at the bedside is uncommon and not standard practice due to the need for specialized equipment and immediate access to emergency care in case of adverse reactions. Therefore, this statement is incorrect.

Title: Choice D Reason:

Taking Metformin as usual before the test is not recommended due to the risk of lactic acidosis when combined with iodinated contrast. As previously mentioned, Metformin should be withheld before and after the procedure until renal function is confirmed to be normal. This precaution helps to prevent any potential complications associated with the interaction between Metformin and the contrast agent.

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During a routine medical evaluation, a client is found to have a random blood glucose level of 310 mg/dL. Which client statements are concerning to the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client?

Correct Answer is C

Explanation

A client with type II diabetes is scheduled to have a computed tomography (CT) scan with IV contrast of the brain to rule out a brain tumor. What health teaching would the nurse include?Your provider will obtain a signed consent from you prior to the completion of the CT scan.

Correct Answer is B

Explanation

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The provider writes an order for a client to have a chest tube removed. Which of the following are appropriate reasons to discontinue a chest tube? Select all that apply.

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