Which test results require the most immediate action by the nurse?

Glycosylated hemoglobin (Hgb A1C) level of 7.5

Random plasma glucose level of 205

A blood glucose prior to the noon meal of 45

Fasting blood glucose level of 300.

Answer and Explanation

The Correct Answer is C

A.   This level indicates average blood glucose over the past 2-3 months and is higher than the target range (usually under 7% for many patients with diabetes). While this result suggests the need for adjustments in management, it is not an immediate emergency.
B.   A random plasma glucose level of 205 mg/dL indicates hyperglycemia, but it is not typically considered an immediate danger unless accompanied by symptoms of hyperglycemia. This level would warrant further monitoring and possibly an adjustment in treatment, but it doesn't require urgent intervention.
C.   A blood glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition that requires immediate action. Hypoglycemia can lead to symptoms such as confusion, seizures, or loss of consciousness, and it must be addressed quickly, usually with fast-acting carbohydrates.
D.   While a fasting blood glucose level of 300 mg/dL indicates significant hyperglycemia, it does not require immediate action like hypoglycemia does. This level indicates a need for further management but is not acutely dangerous compared to a severely low blood glucose level.

Nursing Test Bank

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Correct Answer is D

Explanation

A. In this type of traction, the child’s buttocks should be elevated slightly off the bed to maintain the correct alignment and reduce pressure on the skin. However, a 15° angle may not be specifically necessary for indicating proper traction; what matters more is that the child is positioned correctly and comfortably.
B. While a reduction in pain can indicate that the traction is effective and that the fracture is stabilized, pain management is also influenced by medication and other factors. Therefore, while this is a positive finding, it is not the most definitive indicator of proper traction.
C. However, while it is essential that the pins are secure, the effectiveness of traction is more directly related to the positioning and suspension of the legs rather than just the pin security alone.
D. In Bryant's traction, the legs should be suspended to ensure proper alignment and immobilization of the fractured femur. The traction's effectiveness is best assessed by observing that the legs are correctly suspended and aligned, allowing for the necessary rest and healing of the bone.

A. Avoiding straining during bowel movement or bending at the waist. B. Keep rooms brightly lit C. Lie on your abdomen when in bed. D. Avoid lifting objects weighing more than 15 lbs.

Correct Answer is ["A","D"]

Explanation

A. Patients are often advised to avoid straining during bowel movements and bending at the waist to reduce intraocular pressure and the risk of complications after cataract surgery. This is crucial for promoting healing and preventing dislodgement of the lens.
B. While good lighting can be important for safety and visibility, patients are often advised to avoid excessively bright lights or glare, especially after surgery, as it can be uncomfortable and may not be beneficial during the recovery period. Patients may need to use softer lighting to avoid discomfort.
C. After cataract surgery, patients are typically advised to lie on their back or the non-operative side to avoid pressure on the eye that underwent surgery. Lying on the abdomen is not recommended and could pose a risk to the surgical site.
D. Patients are often instructed to avoid heavy lifting for a period after surgery to prevent increased intraocular pressure and potential complications. Lifting more than 15 lbs is generally discouraged during the initial recovery phase.

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Which test results require the most immediate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 3-year-old is admitted for repair of a fractured femur and is placed in Bryant's traction. Which finding by the nurse indicates that the traction is working properly?

Correct Answer is D

Explanation

The nurse is giving a client discharge instructions following cataract removal with intraocular lens implant. Discharge instructions should include which of the following?

Correct Answer is ["A","D"]

Explanation

A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks the purpose of this medication. Which of the following statements by the nurse is correct?

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The nurse has administered an antacid and a proton pump inhibitor for GERD. Which data would indicate to the nurse that the medications are effective?

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