Exhibits

After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?"
Which are the nurse's best responses? Select all that apply.

"Hyperglycemia often results in weight loss."

"Hyperglycemia often presents as increased thirst and urination."

"Hyperglycemia causes an increased sensation of being hungry."

"Hyperglycemia causes a headache and flushed, dry skin."

"Hyperglycemia causes cool and clammy skin."

Answer and Explanation

Correct Answer : B,C,D

A. "Hyperglycemia often results in weight loss." While chronic uncontrolled hyperglycemia, particularly in Type 1 diabetes, can lead to weight loss due to the body breaking down fat and muscle for energy, this is less typical for the acute or early signs of hyperglycemia.

B. "Hyperglycemia often presents as increased thirst and urination." This is a classic symptom of hyperglycemia, polydipsia (increased thirst) and polyuria (increased urination), caused by the body attempting to eliminate excess glucose through urine.

C. "Hyperglycemia causes an increased sensation of being hungry." Hyperglycemia can cause an increased sensation of hunger (polyphagia), which occurs due to insulin resistance or the body’s inability to use glucose properly.

D. "Hyperglycemia causes a headache and flushed, dry skin." A common symptom of hyperglycemia is headache, and flushed, dry skin can occur due to dehydration from excessive urination.

E. "Hyperglycemia causes cool and clammy skin." Cool and clammy skin is more indicative of hypoglycemia (low blood sugar) rather than hyperglycemia. Hyperglycemia usually presents with warm, dry skin due to dehydration.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Maintain the client on an NPO status: After bariatric surgery, vomiting and the inability to tolerate food and liquids could indicate complications such as gastric outlet obstruction or stenosis. Maintaining NPO status allows the gastrointestinal system to rest while the cause of the symptoms is investigated and treated.

B. Determine if the client is over-hydrating to feel satiated: While over-hydration can cause discomfort, the immediate concern is the client's inability to tolerate food and liquids, which may suggest a more serious issue.

C. Administer daily vitamin supplements: While vitamin supplementation is essential after bariatric surgery to prevent deficiencies, it does not directly address the current issue of vomiting and inability to tolerate food and liquids.

D. Encourage positive self accolades for dietary adherence: Though reinforcing positive behavior is important in long-term weight loss management, it is not the priority at this moment. The immediate focus is addressing the client's symptoms and ensuring they are medically managed.

A. Procure platelet products from the blood bank. B. Titrate oxygen to the prescribed parameters. C. Insert a urinary catheter for an uncomplicated client. D. Monitor an IV infusion rate on an established schedule.

Correct Answer is A

Explanation

A. Procure platelet products from the blood bank: UAPs may be delegated non-invasive tasks such as transporting lab specimens or retrieving blood products. This task does not require nursing judgment and is appropriate for delegation under routine supervision.

B. Titrate oxygen to the prescribed parameters: Titrating oxygen requires assessment and clinical judgment, as adjustments depend on vital signs and client condition. This is within the RN or LPN scope, not the UAP’s, due to the potential for rapid status changes.

C. Insert a urinary catheter for an uncomplicated client: Insertion of catheters is an invasive procedure that requires sterile technique and knowledge of anatomy. This task must be performed by a licensed nurse, not a UAP, even in uncomplicated cases.

D. Monitor an IV infusion rate on an established schedule: Although observation is within the UAP role, monitoring IV infusions involves understanding flow rates, recognizing signs of infiltration or complications, and making clinical decisions, all of which exceed UAP scope.

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Exhibits After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?" Which are the nurse's best responses? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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Exhibits

After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?"
Which are the nurse's best responses? Select all that apply.