The healthcare provider is caring for a client diagnosed with type 2 diabetes mellitus. Which intervention should the healthcare provider implement to assess the client's glycemic control?
- A. Monitor fasting blood glucose levels
- B. Check urine for ketones
- C. Evaluate hemoglobin A1c levels
- D. Assess the client's dietary intake
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?
- A. Confirm the finding by further assessing the client for jugular vein distention.
- B. Offer the client high-protein snacks between regularly scheduled mealtimes.
- C. Continue the planned nursing interventions to restore the client's fluid volume.
- D. Change the plan of care to include interventions for impaired skin integrity.
Correct Answer: C
Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. The appropriate action for the nurse in this situation is to continue the planned nursing interventions aimed at restoring the client's fluid volume. This finding reinforces the need to address the fluid deficit and support the client's recovery.
During a urethral catheterization on a female, where would the healthcare provider observe the urethral meatus after separating the labia?
- A. Between the vaginal orifice and the anus.
- B. Between the clitoris and the vaginal orifice.
- C. Just above the clitoris.
- D. Within the vaginal canal.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?
- A. Document the client's request in the medical record.
- B. Ask the client if this decision has been discussed with his healthcare provider.
- C. Inform the client that a written, notarized advance directive is required to withhold resuscitation efforts.
- D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.
Correct Answer: B
Rationale: When a client expresses the desire to not be resuscitated, it is essential to inquire if this decision has been discussed with their healthcare provider. This is important to ensure that the client's wishes are appropriately documented and legally binding through the healthcare provider's guidance. It is crucial that healthcare decisions, especially those involving life-saving measures, are well-communicated and documented to respect the client's autonomy and ensure their wishes are honored.
A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?
- A. Obtain a prescription from the healthcare provider regarding visitation privileges
- B. Request a consultation with the ethics committee for resolution of the situation
- C. Encourage the client to speak with her husband regarding his disruptive behavior
- D. Communicate the client's wishes to all members of the multidisciplinary team
Correct Answer: B
Rationale: In a situation where a client's estranged husband demands to restrict the visitation of the significant other, it is essential to prioritize the client's wishes while addressing the conflict. Requesting a consultation with the ethics committee is appropriate as it allows for a comprehensive and impartial resolution, ensuring the client's autonomy and well-being are upheld.
The caregiver learns the use of a gait belt from the nurse for a woman with right-sided weakness. The caregiver demonstrates the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly?
- A. Standing on the woman's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
- B. Standing on the woman's weak side, the caregiver provides security by holding the gait belt from the back.
- C. Standing behind the woman, the caregiver provides balance by holding both sides of the gait belt.
- D. Standing slightly in front and to the right of the woman, the caregiver guides her forward by gently pulling on the gait belt.
Correct Answer: B
Rationale: Standing on the weak side of the client and holding the gait belt from the back provides better security and support during ambulation, reducing the risk of falls. This positioning allows the caregiver to offer stability and assistance without interfering with the client's movement, ensuring safe ambulation for the client with right-sided weakness.
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