Patient Data

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 causes cool and clammy skin."

"Hyperglycemia causes an increased sensation of being hungry."

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

"Hyperglycemia often presents as increased thirst and urination."

Answer and Explanation

Correct Answer : D,E

A. "Hyperglycemia often results in weight loss.": Weight loss is more commonly associated with prolonged hyperglycemia, particularly in uncontrolled diabetes where the body starts breaking down fat and muscle for energy.

B. "Hyperglycemia causes cool and clammy skin.": Cool and clammy skin is more indicative of hypoglycemia (low blood sugar) rather than hyperglycemia.

C. "Hyperglycemia causes an increased sensation of being hungry.": Increased hunger is often associated with hypoglycemia or uncontrolled diabetes, where insulin is not effectively managing blood glucose levels.

D. "Hyperglycemia causes a headache and flushed, dry skin.": In cases of significant hyperglycemia, symptoms can include headache and flushed, dry skin due to dehydration. These symptoms arise from the body’s attempt to balance blood sugar levels and manage dehydration.

E. "Hyperglycemia often presents as increased thirst and urination.": Hyperglycemia typically leads to increased thirst (polydipsia) and increased urination (polyuria). This occurs because the body tries to get rid of excess glucose through the urine, leading to dehydration and increased thirst.

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Correct Answer is A

Explanation

A. Kussmaul respirations are deep, labored breathing patterns that help blow off excess carbon dioxide to compensate for metabolic acidosis, which is common in DKA.

B. Diaphoresis is not directly related to the respiratory pattern seen in DKA.

C. Hyperosmolar diuresis explains dehydration but not the respiratory compensation.

D. Erratic electrical impulses are not related to the respiratory pattern of Kussmaul respirations.

A. Call for an assistant. B. Close the room door. C. Finish the procedure. D. Respond to the code.

Correct Answer is A

Explanation

A. The nurse should call for an assistant to take over the tracheostomy care so the nurse can respond to the code blue.

B. Closing the room door is not an appropriate response in this emergency situation.

C. Finishing the procedure would delay the nurse’s response to the code blue, which is urgent.

D. Responding to the code is crucial, but the nurse should ensure the client's tracheostomy care is continued by calling for assistance first.

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Patient Data 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

Correct Answer is A

Explanation

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Correct Answer is A

Explanation

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

The nurse is preparing to administer a suspension ampicillin labeled, 250 mg/5 mL, to a child with impetigo. The prescription is for 500 mg four times a day. How many mL should the child receive per day? (Enter numeric value only.)

The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child's anxiety, which action is best for the nurse to implement?

Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)?

Patient Data 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.

Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Patient Data

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.