Nokea
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.
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A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
- A. Increased collagen
- B. Increased muscle mass
- C. Decreased serum calcium
- D. Decreased circulation
Correct Answer: D
Rationale: Decreased circulation from immobility reduces tissue oxygenation, increasing pressure injury risk.
A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Peripheral edema
- C. Oliguria
- D. Bradycardia
Correct Answer: B
Rationale: Peripheral edema occurs in hypervolemia as excess fluid accumulates in tissues.
A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. High blood pressure
- B. Moist skin
- C. Dark-colored urine
- D. Distended neck veins
Correct Answer: C
Rationale: Dark urine indicates dehydration as kidneys concentrate urine to conserve water.
A nurse is contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings?
- A. Hypoglycemia
- B. Fluid volume overload
- C. Dermatitis
- D. Kidney stones
Correct Answer: C
Rationale: Dermatitis results from prolonged moisture exposure in incontinence, risking skin breakdown.
A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer to monitor her blood glucose. Which of the following actions should the nurse identify as an indication that the client understands the instructions?
- A. Uses the side of a fingertip as the puncture site
- B. Uses the ball of a finger as the puncture site
- C. Avoids using the thumbs as puncture sites
- D. Avoids using the fingers of her dominant hand as puncture sites
Correct Answer: A
Rationale: Using the side of the fingertip is less painful and provides accurate blood samples.