Nokea
A nurse in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?
- A. History of poor wound healing
- B. Random blood glucose 126 mg/dL
- C. Report of decreased urinary output
- D. Clammy skin
Correct Answer: A
Rationale: Poor wound healing is a hyperglycemia sign due to impaired immune response.
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A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?
- A. Tremors
- B. Bradycardia
- C. Decreased appetite
- D. Flushed skin
Correct Answer: A
Rationale: Tremors are a common hypoglycemia symptom due to the body's stress response.
A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?
- A. Hold your breath for 7 seconds when using the incentive spirometer.
- B. Sit up at a 30-degree angle when using the incentive spirometer.
- C. Use the incentive spirometer once every 4 hours.
- D. Inhale through the incentive spirometer 10 times with each use.
Correct Answer: A
Rationale: Holding breath for up to 7 seconds maximizes lung expansion, a key goal of incentive spirometry.
A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?
- A. Withhold the feeding if the residual volume is 150 mL
- B. Flush the tube with 30 mL of sterile water before the feeding
- C. Cleanse the top of the can of formula with an alcohol wipe
- D. Keep the formula cold until instillation
Correct Answer: B
Rationale: Flushing with 30 mL of sterile water ensures tube patency and prevents clogging before feeding.
A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take?
- A. Turn the client onto her side.
- B. Cover the wound with a moist sterile dressing
- C. Apply an abdominal binder to the wound area.
- D. Assure the client that this is an expected occurrence after surgery.
Correct Answer: B
Rationale: Covering with a moist sterile dressing protects the wound and prevents infection in evisceration.
A nurse is collecting data on a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?
- A. Peripheral edema
- B. Oliguria
- C. Hypertension
- D. Bradycardia
Correct Answer: B
Rationale: Oliguria occurs in hypovolemia as kidneys conserve fluid due to low volume.