Exhibits

Nursing actions: Indicated/contraindicated/non-urgent

Teach the client how to count carbohydrates

Stop the insulin infusion

Decrease the frequency of blood glucose tests

Start the client on a regular diet

Decrease the insulin IV infusion to 0.05 units/kg/hr

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

A.   Teach the client how to count carbohydrates - Non-urgent. While essential for long- term management of diabetes, carbohydrate counting is not immediately critical in the acute management phase of HHS in the ICU. This teaching should be delayed until the patient is stabilized.
B.   Stop the insulin infusion - Contraindicated. Stopping insulin in a patient with HHS, which is characterized by severe hyperglycemia, would be harmful. Insulin therapy is critical to reduce blood glucose levels safely.

C.   Decrease the frequency of blood glucose tests - Contraindicated. Frequent monitoring is crucial in managing HHS, especially when insulin therapy is being administered, to prevent hypoglycemia and to monitor the effectiveness of treatment.
D.   Start the client on a regular diet - Contraindicated. Introducing a regular diet during the acute phase of HHS could exacerbate the hyperglycemia. Nutritional needs should be assessed and managed carefully, typically starting with IV fluids and gradually transitioning to enteral or oral feeding as the patient stabilizes.
E.   Decrease the insulin IV infusion to 0.05 units/kg/hr- Indicated. As blood sugar levels decrease, the insulin infusion rate may be cautiously reduced to prevent hypoglycemia.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Scoliosis is a lateral curvature of the spine. It is commonly assessed during routine physical examinations, especially in adolescents.
B. Lordosis refers to an exaggerated inward curvature of the spine, typically in the lumbar region.
C. Torticollis is a condition characterized by a tilt of the head to one side due to the shortening of muscles on one side of the neck.
D. Kyphosis is an exaggerated outward curvature of the thoracic spine, leading to a rounded upper back.

A. Place all client belongings out of reach B. Instruct the client to call before getting up C. Initiate use of the bed alarm D. Complete a swallow study before giving anything by mouth E. Place the client in a room near the elevator F. Provide a call button kept within reach

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

A. placing all client belongings out of reach (A) does not promote safety as it may lead the client to attempt to get up unassisted to retrieve their items, increasing the risk of falls.
B. Instructing the client to call before getting up ensures that assistance is provided, preventing falls due to potential weakness or balance issues.
C. Initiating the use of a bed alarm helps in monitoring the client's movements, which is crucial in preventing falls, especially when the client might have impaired mobility.
D. Completing a swallow study before giving anything by mouth is essential to assess the risk of aspiration, which can be heightened due to possible swallowing difficulties post- stroke.
E. Placing the client in a room near the elevator does not directly promote safety; it could be beneficial for logistical reasons but does not address the client's immediate safety needs.
F. Providing a call button within reach allows the client to alert staff promptly if they need assistance, thus reducing the risk of injury.

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Exhibits Nursing actions: Indicated/contraindicated/non-urgent

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with a routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?

Correct Answer is A

Explanation

Patient Data Exhibits Each row and each column must have at least one, but may have more than one, response option selected. Intervention: Promotes safety/ Does not promote safety

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

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Exhibits

Nursing actions: Indicated/contraindicated/non-urgent