the point diabetes, oxygenation, wound quizzes

Which nutritional deficiency may delay wound healing?

lack of vitamin C

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake which foods should the nurse emphasize?

lean meats and low-fat milk

While caring for a client who's immobile, a nurse documents this information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?

Risk for impaired skin integrity related to immobility

The nurse is offering further education to a client about the management of COPD. Which outcomes would indicate the teaching has been effective? Select all that apply.

The client demonstrates pursed-lip breathing and coughing exercises. The client maintains smoking cessation. The client schedules follow-up physician appointments.

A client concerned about being diagnosed with type 2 diabetes tells a nurse, "My parent suffered with diabetes for many years and finally died of kidney failure in spite of treatment. Why should I try if I'm going to go through the same thing?" What is the nurse's most appropriate response?

"Are you worried that you'll have the same experience as your parent?"

When referred to a podiatrist, a client newly diagnosed with diabetes mellitus asks, "Why do you need to check my feet when I'm having a problem with my blood sugar?" The nurse's most helpful response to this statement is

"Diabetes can affect sensation in your feet and you can hurt yourself without realizing it."

A nurse in a diabetes clinic receives phone calls from four clients with type 1 diabetes. The nurse returns the call of the client reporting what symptoms as highest priority?

"I noticed that my urine has a foul odor, and I have a fever."

Which is the best nursing response to make when a client asks why there are small lumps under the suture line of the incision three weeks after abdominal surgery?

"Those lumps are caused by new tissue growing at different rates."

A client who has been newly diagnosed with type 1 diabetes asks the nurse, "Why do I have to take two shots of insulin? Isn't one shot enough?" What should the nurse tell the client?

"Two shots will give you better control and decrease complications."

A nurse is teaching a client about type 2 diabetes mellitus. What information would reduce a client's risk of developing this disease?

"Maintain weight within normal limits for your body size and muscle mass."

A client says, "I hate the idea of being an invalid after they cut off my leg." Which response by the nurse would be the most therapeutic?

"Tell me more about how you're feeling."

The laboratory comes to draw an Hgb A1c. The client asks the nurse what this test represents. Which statement would be correct?

"This test reflects the average blood glucose over a period of approximately 2-3 months."

A nurse is planning care for a client newly diagnosed with diabetes mellitus type 1. Which statement illustrates an appropriate outcome criterion?

The client will correctly demonstrate blood glucose testing prior to discharge.

A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drip is initiated with 50 units of insulin in 100 ml of normal saline solution administered via an infusion pump set at 10 ml/hour. The nurse determines that the client is receiving how many units of insulin each hour? Record your answer using a whole number.

5

Every morning, a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?

70% NPH insulin and 30% regular insulin

Mr. Jay presents with a day of severe abdominal pain. He is scheduled for a CT scan with contrast. One of his home medications is metformin (Glucophage). Once the test is completed the nurse anticipates:

Holding the metformin (Glucophage) for 48 hours

The nurse has been assigned to a client who has had diabetes for 10 years. The nurse gives the client's usual dose of regular insulin at 7 a.m. At 10:30 a.m., the client has light-headedness and sweating. The nurse should contact the physician, report the situation, background, and assessment, and recommend intervention for:

Hypoglycemia

A nurse is teaching a new diabetic client to administer insulin. How will the nurse evaluate if the teaching interventions were appropriate?

Observe the client demonstrate an insulin injection and correctly identify the injection site rotation.

A client is coming to the clinic for a follow-up appointment after taking metformin for 9 months. After reviewing the client's HbA1C level of 8.5%, the nurse anticipates what response from the healthcare provider?

Order an additional oral antidiabetic agent.

Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?

The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.

A client is admitted to the emergency department with crushing chest injuries sustained in a car crash. The nurse is assessing the client's respiratory status. Which sign indicates a possible complication that the nurse should report to the health care provider immediately?

absent breath sounds on the affected side

When developing a teaching plan for a client with an infected decubitus ulcer, the nurse should tell the client that which factor is most important for healing?

adequate circulatory status

The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation?

arterial blood gases

An adolescent with insulin-dependent diabetes is being taught the importance of rotating the sites of insulin injections. The nurse should judge that the teaching was successful when the adolescent identifies which complication that can result from using the same site?

destruction of the fat tissue and poor absorption

The nurse is assessing a client with pneumonia. Which change in the client's mental status is concerning at this time?

irritability

A client tells the nurse he is experiencing dyspnea. Which position will the nurse place the client in?

high Fowler's position

An infant requires tracheal suctioning after the nurse assesses airway congestion. Which is the priority initial action when performing the procedure?

oxygenation prior to the procedure

When educating unlicensed nursing personnel (UAP) about how to prevent the development of pressure ulcers, the nurse should emphasize that most tissue injuries related to shearing can be prevented by:

proper positioning and moving of the client.

After being sick for three days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). Which diagnostic test will the nurse prioritize in monitoring?

serum potassium level

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 × 1-inch (3 × 3-cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record?

stage II pressure ulcer

A client with newly diagnosed type 2 diabetes is admitted to the metabolic unit. The primary goal for this admission is education. Which goal should the nurse incorporate into their teaching plan?

weight reduction through diet and exercise

A school-age child experiences symptoms of excessive polyphagia, polyuria, and weight loss. The physician diagnoses type 1 diabetes and admits the child to the facility for insulin regulation. The physician orders an insulin regimen of insulin and isophane insulin administered subcutaneously. How soon after administration can the nurse expect the regular insulin to begin to act?

½ to 1 hour

The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include?

Apply a hydrocolloidal dressing.

The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care?

Place the client on a pressure redistribution bed.

To prevent oral complications when using a fluticasone metered-dose inhaler, a nurse should instruct the client to do what? Select all that apply.

Rinse out the mouth after using the inhaler. Add a spacer to the metered dose inhaler. Keep the mouth piece from becoming contaminated.

The nurse is receiving results of a blood glucose level from the laboratory over the telephone. What should the nurse do?

Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller.

When planning care for a group of clients, the nurse should identify which client as having the greatest risk for the development of pressure ulcers?

a client who has a decreased serum albumin level

A nurse is teaching a school-age child with diabetes and their parents about managing diabetes during illness. The nurse determines that the parents understand the instruction when they indicate that they will make which treatment plan modification on days when the child is ill?

increasing the frequency of blood glucose monitoring

A nurse is reviewing the medications used by a client who has chronic bronchitis and a history of high blood pressure and prostate enlargement. The nurse should verify that the client understands that which medications should be avoided because of the risks they pose? Select all that apply.

guaifenesin with dextromethorphan liquid generic pseudoephedrine tablets

Which combination of adverse effects should a nurse monitor for when administering I.V. insulin to a client with diabetic ketoacidosis?

hypokalemia and hypoglycemia

A nurse is assessing a client at the beginning of the shift. Which signs of hypoxia would alert the nurse to take further action?

increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis

The nurse is caring for an immobile client. Which intervention should the nurse prioritize?

keeping the skin clean and dry with gentle soap

A nurse is providing dietary instructions to a client with diabetes. What is most important for the nurse to include in teaching for prevention of hypoglycemia?

Avoid delaying or skipping meals.

A nurse evaluates a new patient as having a Braden scale score of 9. What is the nurse's interpretation of this finding?

The patient is at severe risk for pressure ulcer development and prevention precautions must be instituted immediately

When caring for a patient with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently?

Using normal saline solution to clean the ulcer and applying a protective dressing as necessary

The nurse is performing wound care on a client with an open fracture. What is the nurse's priority action to clean the wound?

Irrigate the wound with normal saline.

A client with diabetes is being tested for glycosylated hemoglobin. How would the nurse explain the reason for this diagnostic test?

It determines the average blood glucose level in the previous 2-3 months.

The nurse is bathing a client and discovers a pressure ulcer on the buttocks (see photo). Which nursing intervention, following completion of the bath, is completed first?

Position the client off of the ulcer.

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing?

The dressing should keep the wound moist.

The community health nurse is working with a client who has limited mobility. Which interventions would the nurse implement for primary prevention of skin breakdown? Select all that apply.

encouragement of the client to walk around the home three times a day education of the client on turning frequently in the bed if lying down instruction on the application of lotion for dry skin on extremities

A nurse is providing wound care to a client 1 day after an appendectomy. A drain was inserted into the incisional site during surgery. What should the nurse do to provide wound care?

Clean the area around the drain, moving away from the drain.

The nurse assesses a client with a fever and a draining arm wound. The healthcare provider suspects a methicillin-resistant Staphylococcus aureus (MRSA) infection and issues orders. What health care provider order will the nurse implement first?

Cleanse the area around the wound, and obtain a culture.

The nurse is conducting an assessment of an elderly client who is blind. What would the nurse expect to be present in the client's medical history?

diabetes mellitus

An adolescent with well-controlled type 1 diabetes has assumed complete management of the disease and wants to participate in gymnastics after school. To ensure safe participation, the nurse should instruct the client to adjust the therapeutic regimen by:

eating a snack before each gymnastics practice.

A nurse is instructing a patient with asthma on the use of an inhaler with a spacer. The patient asks what the purpose of the spacer is. The nurse's best response is:

"The spacer traps medicine from the inhaler, then breaks up and slows down the medication particles, so you get more medication."

A client with diabetes begins to cry and says, "I just can't stand the thought of having to give myself a shot every day." What would be the best response by the nurse?

"What bothers you about giving yourself the insulin shots?"