The nurse has reviewed the nurses' notes at 0940, vital signs at 0945, and laboratory reports at 1020.

For each assessment finding, click to specify if the finding is consistent with diabetes, pancreatitis, or hyperthyroidism. Each finding may support more than one disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Weight

Heart rate

T3 level

Blood glucose

Answer and Explanation

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

Diabetes:
• Weight
• Blood glucose

Pancreatitis:
• None

Hyperthyroidism:
• Heart rate
• T3 level

Rationale:

• Weight: The client has experienced unintended weight loss, which is a common symptom of diabetes due to the body's inability to use glucose effectively, leading to fat and muscle breakdown.

• Heart rate: Tachycardia is a hallmark of hyperthyroidism due to increased metabolic activity and sympathetic nervous system stimulation.

• T3 level: The T3 level is within the normal range but on the higher end, which can still support hyperthyroidism when considered with other clinical findings.

• Blood glucose: An elevated blood glucose level of 250 mg/dL is consistent with diabetes, as normal fasting levels are below 106 mg/dL.

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Correct Answer is B

Explanation

A. Closing the inline clamp is necessary when the catheter is not in use to prevent air embolism, but it is not a required step before administering medication. The nurse should focus on flushing and checking for patency before medication administration.

B. Flushing the catheter with 10 mL of 0.9% sodium chloride before and after medication administration helps maintain patency, prevents occlusion, and ensures the catheter is functioning properly. This step is essential to avoid complications such as clot formation.

C. Applying a local anesthetic is not needed for routine medication administration through a nontunneled percutaneous central catheter. Anesthetic use is typically reserved for procedures like catheter insertion or painful dressing changes.

D. Donning sterile gloves is not required for medication administration through a central line. Clean gloves are sufficient, while sterile technique is reserved for dressing changes and catheter insertions.

A. Inspect the mouth once each week for sores. B. Use text or pictures to communicate needs postoperatively. C. Rinse with an alcohol-based mouthwash instead of brushing. D. Increase intake of dense, high-fiber foods.

Correct Answer is B

Explanation

A. Inspect the mouth once each week for sores: Frequent oral assessments are necessary, especially after a partial glossectomy, to monitor for infection, healing complications, or signs of malignancy recurrence. Checking only once per week is insufficient for early detection of issues.

B. Use text or pictures to communicate needs postoperatively: A partial glossectomy can impair speech, making communication difficult. Using alternative methods such as writing, text, or pictures helps ensure effective communication, especially in the immediate postoperative period.

C. Rinse with an alcohol-based mouthwash instead of brushing: Alcohol-based mouthwashes can cause irritation and delay healing. Instead, gentle oral hygiene with a soft toothbrush and non-alcoholic rinses like saline or chlorhexidine is recommended to maintain cleanliness without irritation.

D. Increase intake of dense, high-fiber foods: Soft, easy-to-swallow foods are preferred after a partial glossectomy to prevent irritation and facilitate healing. Dense, high-fiber foods can be difficult to chew and may cause discomfort, increasing the risk of aspiration or delayed wound healing.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a medication for a client through a nontunneled percutaneous central catheter. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who is postoperative following a partial glossectomy. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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