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A nurse is reviewing blood glucose values for a client who is at risk for Diabetes Mellitus. Which of the following findings should the nurse report to the provider?
- A. 2-hour glucose tolerance test level 150 mg/dL
- B. Fasting blood glucose 70 mg/dL
- C. Glycosylated hemoglobin 5%
- D. Casual blood glucose 90 mg/dL
Correct Answer: A
Rationale: The correct answer is A. A 2-hour glucose tolerance test level of 150 mg/dL is above the normal range and should be reported to the provider as it indicates impaired glucose tolerance. Choice B (Fasting blood glucose 70 mg/dL) is within the normal range. Choice C (Glycosylated hemoglobin 5%) is also within the normal range. Choice D (Casual blood glucose 90 mg/dL) is within the normal range and does not indicate impaired glucose tolerance.
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A healthcare professional is reviewing the lab findings of a client who has Clostridium Difficile. Which of the following findings should indicate to the healthcare professional that the client is experiencing Fluid Volume Deficit?
- A. Hct 53%
- B. Potassium 3.5
- C. Sodium 145
- D. HbA1c 5
Correct Answer: A
Rationale: An elevated hematocrit level (Hct 53%) indicates hemoconcentration, a sign of fluid volume deficit. Hct measures the percentage of red blood cells in the blood and increases when there is a decrease in plasma volume, as seen in fluid volume deficit. Choices B, C, and D do not directly relate to fluid volume status. Potassium and sodium levels are more indicative of electrolyte imbalances, while HbA1c reflects average blood sugar levels over the past 2-3 months and is not specific to fluid volume status.
During an initial visit with an older adult client living alone and having difficulty preparing meals, what should the home health nurse do first?
- A. Discuss nutritional requirements with the client.
- B. Refer the client to a senior citizen center.
- C. Arrange for a home-delivered meal program.
- D. Perform a nutrition screening.
Correct Answer: D
Rationale: Performing a nutrition screening is the most appropriate action for the nurse to take first. This allows the nurse to assess the client's current nutritional status and identify any specific needs. Discussing nutritional requirements with the client (Choice A) may be important but should come after the initial assessment. Referring the client to a senior citizen center (Choice B) or arranging for a home-delivered meal program (Choice C) are actions that may be considered later based on the findings of the nutrition screening.
A nurse is teaching a client about strategies to prevent constipation. Which of the following statements by the client indicates an understanding of the teaching?
- A. Drinking four to five glasses of water per day will prevent constipation.
- B. I should consume mineral oil once per day.
- C. Eating foods high in fiber will make elimination easier.
- D. I can skip a meal if I feel bloated.
Correct Answer: C
Rationale: The correct answer is C. Eating foods high in fiber increases stool bulk and promotes easier elimination, thus preventing constipation. Choices A, B, and D are incorrect. Drinking water is important, but the emphasis should be on high-fiber foods. Mineral oil is not a recommended first-line treatment for constipation, and skipping meals can disrupt regular bowel movements, potentially leading to constipation.
A nurse is discussing denture care with the partner of a client who is unable to perform oral hygiene. Which of the following should be included in the discussion?
- A. Floss dentures as part of daily cleaning.
- B. Wipe dentures before storing them in a dry container at night.
- C. Wrap gloved fingers with gauze to remove dentures.
- D. Use a washcloth to clean the denture surfaces.
Correct Answer: C
Rationale: The correct answer is C: 'Wrap gloved fingers with gauze to remove dentures.' This method provides a safe and effective way to remove dentures without causing damage. Choice A is incorrect because flossing dentures is not recommended. Choice B is incorrect as it suggests wiping dentures and storing them dry, which is not the best practice. Choice D is incorrect because using a washcloth may not effectively clean all denture surfaces.
A nurse is providing nutritional education to a client who is obese. The nurse should include in the information that which of the following gastrointestinal disorders is commonly associated with obesity?
- A. Peptic ulcer disease
- B. Gastroesophageal reflux disease
- C. Celiac disease
- D. Crohn's disease
Correct Answer: B
Rationale: Gastroesophageal reflux disease (GERD) is commonly associated with obesity due to increased abdominal pressure and other factors. Peptic ulcer disease (Choice A) is not commonly associated with obesity. Celiac disease (Choice C) is an autoimmune disorder triggered by gluten consumption and is not directly linked to obesity. Crohn's disease (Choice D) is a type of inflammatory bowel disease and is not specifically associated with obesity.