Try Naxlex NCLEX-RN (Free-Trial)

Exhibits

Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

B. This statement encourages the client to actively participate in their dietary planning by involving them in the process of selecting foods they enjoy. It empowers the client to collaborate with the dietitian in creating a meal plan that suits their preferences

A While empathetic, it does not actively encourage the client's involvement in their care plan or decision-making process.

C. While this statement reassures the client about the expertise of the dietitian, it does not actively encourage the client's active participation or involvement in decision-making regarding their dietary choices.

D. This statement acknowledges the need for adjustments but does not specifically encourage the client's active involvement in planning their dietary choices.

A. Perforation of the eardrum B. Born with a high birth weight C. Frequent exposure to low-volume noise D. Chronic infections of the middle ear E. Use of a loop diuretic

Correct Answer is ["A","D","E"]

Explanation

A A perforated eardrum can lead to conductive hearing loss, where sound waves cannot efficiently travel through the middle ear to the inner ear.

D. Chronic infections of the middle ear (otitis media) can cause damage to the delicate structures of the middle ear, including the ossicles (bones) and the eardrum, leading to conductive hearing loss or, if severe and untreated, sensorineural hearing loss.

E. Loop diuretics such as furosemide can sometimes cause ototoxicity, which means they can damage the inner ear and lead to hearing loss. This is an important consideration for individuals who are prescribed loop diuretics for medical conditions.

B. High birth weight is not typically considered a significant risk factor for hearing loss unless it was associated with other complications that affected the ears during infancy or childhood.

C. Frequent exposure to low-volume noise is not typically associated with an increased risk of hearing loss

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

ExhibitsThe nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

Exhibits The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.

A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

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?

A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching?

A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

Exhibits Which of the following actions should the nurse take? For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

A nurse is caring for a client who has oral achalasia. The nurse should ask the client which of the following questions to assess their ability to swallow?