The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?
Hard, painless nodule over metatarsophalangeal joint of first toe.
Erythema and edema at the base of the left great toe.
Decreased response to pain discrimination on dorsal surface of foot.
Painful corns and calluses over hammer toes on both feet.
The Correct Answer is B
A. A hard, painless nodule may indicate a deformity but is not an emergency.
B. Erythema and edema at the base of the left great toe could indicate an infection, such as cellulitis, which requires immediate intervention to prevent complications.
C. Decreased response to pain discrimination suggests neuropathy, which is concerning but not immediately life-threatening.
D. Painful corns and calluses are chronic issues that need management but are not urgent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To administer the correct dose of acetaminophen, the client needs to take 1,000 mg. Since the oral suspension is 500 mg per 15 mL, the client would need 30 mL to get the 1,000 mg dose. There are 15 mL in one tablespoon, so the client should take two tablespoons to equal the 30 mL required for the 1,000 mg dose.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
A. Given the client's chronic kidney disease and the risk of fluid overload, a high rate of normal saline infusion may not be appropriate without careful assessment and specific indication from the healthcare provider.
B. Monitoring daily weight is essential in managing fluid balance and assessing for potential fluid overload, especially in a child with chronic kidney disease.
C. Accurate measurement of intake and output is crucial in managing fluid balance and monitoring kidney function, particularly in a patient with a history of acute kidney injury and chronic kidney disease.
D. The client already has an elevated potassium level, and administering a potassium-sparing diuretic could worsen hyperkalemia, leading to dangerous cardiac complications.
E. Continuous monitoring of oxygen saturation is important due to the presence of bibasilar infiltrates on the chest X-ray, which could indicate a potential respiratory issue.
F. ECG monitoring is indicated due to the elevated potassium level (5.3 mEq/L), which can cause cardiac arrhythmias. The irregular heart rate further supports the need for ECG monitoring.
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