The nurse has reviewed the provider prescriptions at 1045.

Exhibits

Which of the following actions should the nurse perform first?

Apply dressing to foot wound.

Consult outpatient wound care specialist.

Schedule appointment with ophthalmologist.

Administer regular insulin 4 units subcutaneously x 1 dose

None

Answer and Explanation

The Correct Answer is D

Apply dressing to foot wound: While wound care is important, managing hyperglycemia takes priority. High blood glucose impairs wound healing and increases infection risk, making insulin administration the more urgent intervention. Dressing application should follow glycemic control measures.

Consult outpatient wound care specialist: A wound care consultation is appropriate for managing a chronic ulcer, but immediate intervention is required to stabilize glucose levels. Optimizing wound care should come after initial glucose management.

Schedule appointment with ophthalmologist: Clients with diabetes require routine eye exams due to the risk of diabetic retinopathy. However, addressing hyperglycemia and preventing further infection are more urgent concerns at this time.

Administer regular insulin 4 units subcutaneously x 1 dose: The client's blood glucose is elevated (250 mg/dL), which can impair immune function and tissue healing. Lowering glucose with insulin is the priority to prevent complications such as worsening infection or ketoacidosis.

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 C

Explanation

A. "Eat a light meal 1 hour before bedtime.": Eating before bedtime increases the risk of acid reflux because lying down soon after eating allows stomach contents to flow back into the esophagus. It is recommended to avoid eating at least 2 to 3 hours before lying down.

B. "Lie down for 30 minutes after each meal.": Lying down after meals promotes reflux by reducing the effect of gravity in keeping stomach contents in place. Instead, clients should remain upright for at least 2 hours after eating to minimize symptoms.

C. "Sleep with the head of your bed elevated 6 inches.": Elevating the head of the bed helps prevent stomach acid from flowing back into the esophagus by using gravity to reduce reflux symptoms. This is a well-established lifestyle modification for GERD management.

D. "Increase your caloric intake by 250 calories per day.": Increasing caloric intake is not a recommended intervention for GERD. Excess weight can worsen symptoms by increasing intra-abdominal pressure, so weight management is often advised for clients with GERD.

A. Sore throat B. SaO2 92% C. Stridor D. Rhonchi

Correct Answer is C

Explanation

A. Sore throat: A sore throat is a common and expected finding after extubation due to irritation and mild inflammation of the airway. While discomfort may persist, it does not typically require immediate intervention.

B. SaO2 92%: An oxygen saturation of 92% is slightly lower than normal but is generally acceptable in most patients following extubation. Close monitoring is necessary, but immediate intervention is not required unless the saturation continues to decline.

C. Stridor: Stridor is a high-pitched, harsh sound caused by upper airway obstruction, often due to post-extubation laryngeal edema. This is a medical emergency requiring immediate intervention, such as administration of nebulized epinephrine, corticosteroids, or reintubation if severe airway compromise occurs.

D. Rhonchi: Rhonchi are low-pitched, coarse lung sounds caused by mucus or secretions in the airways. This finding may indicate the need for suctioning or respiratory therapy but does not require urgent intervention compared to stridor.

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

The nurse has reviewed the provider prescriptions at 1045. Exhibits Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately

Correct Answer is C

Explanation

A nurse is caring for a client who had a total right hip arthroplasty. In which of the following positions should the nurse place the client to prevent complications?

A nurse is assessing the abdominal wound of a client who is 3 days postoperative following a colon resection. Which of the following findings should the nurse report to the provider?

A nurse is assessing a client who is taking lisinopril. Which of the following findings should the nurse document in the client's medical record as an adverse effect?

A nurse is caring for a client who is receiving potassium chloride 40 mEq IV every 4 hr. Which of the following findings indicate the client is becoming hyperkalemic?

A nurse is caring for a client who has end-stage cancer and is receiving chemotherapy. The client tells the nurse, "I want to discontinue treatment, but my children insist I continue." Which of the following responses should the nurse make?

A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?

A nurse in a provider's office is caring for a client. For each client's finding, click to specify if the assessment finding is consistent with sickle cell disease, iron deficiency anemia, and/or pernicious anemia. Each finding may support more than 1 disease process.

A nurse is assessing a client who is 24 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

The nurse has reviewed the provider prescriptions at 1045.

Exhibits

Which of the following actions should the nurse perform first?