Exhibits
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1400:
Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg/dL (74 to 106 mg/dL)
1400:
Temperature 36.8° C (98.2° F) Pulse rate 84/min Respiratory rate 16/min
Blood pressure 106/76 mm Hg Oxygen saturation 96% on room air
Client urinating 100 mL/hour
Client is tolerating soft diet and oral fluids
Bilateral pedal pulses 2+
Blood glucose 310 mg/dL (74 to 106 mg/dL)
Pulse rate 84/min
Respiratory rate 16/min
Blood pressure 106/76 mm Hg
Oxygen saturation 96% on room air
admitted to the medical-surgical unit at 1200 today
Alert and orientated x4
The Correct Answer is ["A","B","C","D","E","F","G"]
Blood glucose 310 mg/dL (74 to 106 mg/dL)
The initial blood glucose level was 468 mg/dL, indicating severe hyperglycemia, likely due to diabetic ketoacidosis (DKA). The decrease to 310 mg/dL suggests that the insulin therapy is starting to bring the blood glucose levels down towards normal range. This reduction is a positive sign of response to treatment.
Client urinating 100 mL/hour
This indicates improved kidney function compared to the initial presentation where the client reported frequent urination and nausea. Adequate urine output (typically more than 30 mL/hour) is crucial in managing DKA as it signifies improved renal perfusion and clearance of ketones and glucose from the blood.
Client is tolerating soft diet and oral fluids
This indicates improvement in gastrointestinal function and resolution of nausea, which is consistent with the ondansetron administration for nausea control. It also suggests that the client's appetite and overall condition are improving.
Bilateral pedal pulses 2+
Initially, the pulses were 1+, indicating poorer peripheral perfusion. Bilateral pedal pulses becoming 2+ suggest improved circulation, likely due to the correction of acidosis and hydration status with fluid and electrolyte
Blood pressure
The improvement in the blood pressure indicates that the client is out of the dehydration state caused by DKA.
Pulse rate
Resolution of tachycardia is a good indicator of improved hydration status
Respiratory rate
The decrease in respiratory rate is an indicator of improving acidosis and resolution of Kussmaul breathing common in DKA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A Checking the pulse distal (beyond) to the AV graft site is crucial to assess peripheral circulation. It helps determine if the graft is adequately perfusing blood to the distal extremity. Absence or weak pulse distal to the graft could indicate graft malfunction or complications such as thrombosis or inadequate blood flow.
B. Splinting the forearm may help immobilize the arm and reduce movement that could potentially disrupt the AV graft site. However, immobilization should be balanced with promoting mobility and preventing complications such as joint stiffness or pressure injuries.
C. Drawing blood from the AV graft could introduce infection risk or damage the graft site. It is standard practice to avoid using the AV graft for routine blood draws
D. Positioning the forearm below the level of the heart promotes venous return and reduces swelling or edema in the extremity. However, for an AV graft, maintaining the arm in a dependent position should be avoided to prevent excessive pressure on the graft site or compromising blood flow.
Correct Answer is C
Explanation
B. This statement indicates understanding of preventive measures to reduce the risk of transmitting genital herpes to sexual partners. Using condoms, including natural skin (non-latex) condoms, can help reduce the risk of transmission.
A Antiviral medications for genital herpes are typically prescribed to manage outbreaks and reduce symptoms, but the duration can vary depending on the severity of symptoms and recurrence.
b. People with genital herpes should use latex or polyurethane condoms during sexual intercourse, as these are effective at reducing the risk of transmitting the virus. Natural skin condoms (e.g., lambskin condoms) do not provide an effective barrier against the herpes virus because they have tiny pores that can allow the virus to pass through, potentially leading to transmission.
C. These typically heal within 2-4 weeks. While some might take longer, 6 weeks provides a reasonable timeframe for most cases.
D. Antibiotic ointments are not effective against viruses such as herpes simplex virus (HSV). Treatment for genital herpes typically involves antiviral medications
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