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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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

C. Lowering the bed height reduces the risk of injury in case the client falls out of bed. It also facilitates easier transfers for clients with mobility issues.

A Individuals with dementia may experience disorientation and confusion, especially in unfamiliar or dark environments. Turning off all lights can increase the risk of falls and accidents.

B. Clients with dementia may have difficulty recognizing the need to toilet or may forget where the bathroom is located. They may also have urinary or fecal incontinence. Scheduled toileting helps prevent accidents and promotes continence.

D. Sedatives or hypnotic medications can increase confusion, risk of falls, and adverse effects in older adults with dementia. They are generally not recommended as first-line treatment for sleep disturbances in dementia.

A. "Rinse your mouth with hydrogen peroxide." B. "Brush your teeth for 60econds twice daily." C. "Wear your dentures only during meals." D. "Floss your teeth gently following each meal."

Correct Answer is D

Explanation

A Hydrogen peroxide can be too harsh and irritating to inflamed oral mucosa. It may further aggravate mucositis and delay healing. Therefore, it is not appropriate to recommend rinsing with hydrogen peroxide for a client with mucositis.

B. Brushing for 60 seconds is not enough.

C. Dentures can exacerbate mucositis by causing friction and pressure on the gums and oral mucosa. To reduce irritation, clients should remove dentures when not eating to give their gums and oral tissues a chance to rest and recover.

D. Flossing can help remove food particles and plaque from between the teeth, which could otherwise contribute to infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?

Correct Answer is C

Explanation

A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following responses should the nurse make?

A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include?

A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?

Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client dropdown followed by the client's dropdown

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hr. Which of the following actions should the nurse take in managing the client's PICC line?

A nurse is teaching a client who has asthma about how to use a metered-dose inhaler with a spacer. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make?