Nokea
A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
- A. Partial-thickness skin loss with red tissue in the wound bed.
- B. Intact skin with localized erythema.
- C. Full-thickness skin loss with visible adipose tissue.
- D. Full-thickness skin loss with visible bone.
Correct Answer: A
Rationale: Stage 2 pressure injuries show partial-thickness loss with a red wound bed, indicating damage to epidermis and possibly dermis.
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A nurse is reinforcing teaching about the manifestations of hyperglycemia with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. My breath may have a fruity odor.
- B. I will be more thirsty than usual.
- C. My appetite will be decreased.
- D. I might experience blurry vision at times.
Correct Answer: B
Rationale: Increased thirst (polydipsia) is a classic hyperglycemia symptom due to dehydration from glucose excretion.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?
- A. Manifestations of hypoglycemia
- B. Height of the IV pole
- C. IV insertion site
- D. The client's oral intake
Correct Answer: C
Rationale: Monitoring the IV insertion site is critical for TPN due to the high risk of infection and complications with central lines.
A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?
- A. BMI of 20
- B. Peripheral neuropathy
- C. Immobility
- D. Hypoperfusion
- E. Prealbumin level of 16 mg/dL
Correct Answer: B,C,D,E
Rationale: B: Neuropathy reduces sensation. C: Immobility causes prolonged pressure. D: Hypoperfusion impairs tissue oxygenation. E: Low prealbumin indicates poor nutrition.
A nurse administers subcutaneous NPH insulin at 0700 to a child who has diabetes. At which of the following times should the nurse observe for hypoglycemia caused by the onset of the medication?
- A. 715
- B. 730
- C. 1200
- D. 900
Correct Answer: D
Rationale: NPH insulin onset is 1-2 hours; 0900 (2 hours post-0700) is when hypoglycemia may begin.
A nurse is caring for a client who has gestational diabetes and reports feeling shaky, sweaty, and having blurred vision. The client's blood glucose level is 48 mg/dL. Which of the following foods should the nurse give to the client? (Select all that apply).
- A. 1 tbsp honey
- B. 120 mL milk
- C. 5 hard candies
- D. 240 mL regular soda
- E. 120 mL unsweetened fruit juice
Correct Answer: A,B,C,D
Rationale: A, B, C, D provide quick sugar sources to correct hypoglycemia; unsweetened juice (E) lacks sufficient glucose.