HEC Final (Diabetes, Infection, Tissue Integrity)

The nurse is caring for a client who is 2 days postoperative following an abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin according to capillary blood glucose testing four times a day. A carbohydrate-controlled diet has been prescribed but the client has been complaining of nausea and is not eating. On entering the client's room, the nurse finds the client to be confused and diaphoretic. Which action is most appropriate at this time? A. Call a code to obtain needed assistance immediately. B. Obtain a capillary blood glucose level and perform a focused assessment. C. Ask the unlicensed assistive personnel (UAP) to stay with the client while obtaining 15 to 30 g of a carbohydrate snack for the client to eat. D. Stay with the client and ask the UAP to call the health care provider (HCP) for a prescription for intravenous 50% dextrose.

B. Diaphoresis and confusion are signs of moderate hypoglycemia. A likely cause of the client's change in condition could be related to the administration of insulin without the client eating enough food. However, an assessment is necessary to confirm the presence of hypoglycemia. The nurse would obtain a capillary blood glucose level to confirm the hypoglycemia and perform a focused assessment to determine the extent and cause of the client's condition. Once hypoglycemia is confirmed, the nurse stays with the client and asks the unlicensed assistive personnel (UAP) to obtain the appropriate carbohydrate snack. A code is called if the client is not breathing or if the heart is not beating.

A client newly diagnosed with diabetes mellitus is instructed by the health care provider to obtain glucagon for emergency home use. The client asks a home care nurse about the purpose of the medication. What is the nurse's best response to the client's question? A. "It will boost the cells in your pancreas if you have insufficient insulin." B. "It will help promote insulin absorption when your glucose levels are high." C. "It is for the times when your blood glucose is too low from too much insulin." D. "It will help prevent lipoatrophy from the multiple insulin injections over the years."

C. Glucagon is used to treat hypoglycemia resulting from insulin overdose. The family of the client is instructed in how to administer the medication. In an unconscious client, arousal usually occurs within 20 minutes of glucagon injection. When consciousness has been regained, oral carbohydrates should be given. Lipoatrophy and lipohypertrophy result from insulin injections.

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do? A. Eat twice the amount normally eaten at lunchtime. B. Take half the amount of prescribed insulin on practice days. C. Eat a small box of raisins or drink a cup of orange juice before soccer practice. D. Take the prescribed insulin at noontime rather than in the morning.

C. Hypoglycemia is a blood glucose level less than 70 mg/dL and results from too much insulin, not enough food, or excessive activity. An extra snack of 15 to 30 g of carbohydrates eaten before activities such as soccer practice would prevent hypoglycemia. A small box of raisins or a cup of orange juice provides 15 to 30 g of carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be doubled.

A discharged obese client will require frequent dressing changes for a skin condition on his left foot. How does the nurse assess whether the client is able to perform this task at home? A. Asks the client if he is squeamish B. Demonstrates how to change the dressing C. Determines whether the client can reach the affected area D. Provides all of the necessary dressing materials

C. Whether the obese client can access the dressing site is the most important thing to assess; if the dressing site cannot be accessed by the client, it will be difficult for the client to perform frequent dressing changes at home. The nurse would have already assessed the client's squeamishness during in-hospital dressing changes. A demonstration of how to change the dressing and providing the dressing materials are a good start, but they do not assess the client's ability to perform the task himself.

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? A. Avoiding infection B. Taking in adequate fluids C. Preventing and recognizing hypoglycemia D. Preventing and recognizing hyperglycemia

D. In the test result for glycosylated hemoglobin A1c, 7% or less indicates good control, 7% to 8% indicates fair control, and 8% or higher indicates poor control. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes

A client has had a melanoma lesion removed. For secondary prevention, what is important for the nurse to teach the client? A. Ensure that all lesions are reviewed by a dermatologist or a surgeon. B. Avoid sun exposure. C. Perform a total skin self-examination monthly. D. Perform a total skin self-examination monthly with a partner.

D. Performing a monthly total skin self-examination with another person is the best secondary preventive measure. If the client is taught to use the ABCDE (asymmetry, border, color, diameter, and evolving) method of lesion assessment, the client will know whether a lesion warrants assessment by a specialist. Avoiding sun exposure is primary prevention. It is difficult for a person to assess all of the skin surfaces of his or her body by him- or herself, even with the use of mirrors. It is better to involve a partner with the assessment.

The home care nurse is visiting a child newly diagnosed with diabetes mellitus. The nurse is instructing the child and parents regarding actions to take if hypoglycemic reactions occur. The nurse should tell the child to take which action? A.Administer glucagon immediately if shakiness is felt. B. Drink 8 ounces of diet cola at the first sign of weakness. C. Report to a hospital emergency department if the blood glucose is 60 mg/dL. D. Carry hard candies whenever leaving home in case a hypoglycemic reaction occurs.

D. The child should be instructed to carry a source of glucose for ready use in the event of a hypoglycemic reaction. Hard candies such as LifeSavers will provide a source of glucose. Glucagon is not administered if shakiness is felt but is used in an unconscious client or a person unable to swallow who is experiencing a hypoglycemic reaction. A diet beverage is sugar-free and will not be helpful. If the blood glucose level is 60 mg/dL, a source of glucose may be needed, but it is not necessary to report to the emergency department.

A client is receiving parenteral nutrition (PN). The nurse monitors the client for complications of the therapy and should assess the client for which manifestations of hyperglycemia? A. Fever, weak pulse, and thirst B. Nausea, vomiting, and oliguria C. Sweating, chills, and abdominal pain D. Weakness, thirst, and increased urine output

D. The high glucose concentration in PN places the client at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's respirations, diuresis, and coma when hyperglycemia is severe. If the client has these symptoms, the blood glucose level should be checked immediately. The remaining options do not identify signs specific to hyperglycemia.

The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? A. "I must stop taking my birth control pills." B. "I should drink lots of water so I don't get dehydrated." C. "I should exercise my legs when I have been sitting or standing for a long time." D. "If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

D. Wearing the graduated compression stockings is a prevention specific to the hospital setting; they are designed to prevent blood clots, unlike regular pantyhose. Discontinuation of birth control pills is a routine prevention for thromboembolism, but this prevention is not specific to the client's acute hospitalization. Drinking a lot of water, where the quantity is not specified, may not be indicated for this client. Exercise is a prevention that can be done outside the hospital.

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? A. Ankle-brachial index B. Dye allergy C. Pedal pulses D. Gag reflex

C. Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring for distal pulses. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses). Ankle-brachial index is a diagnostic study used to detect the presence of PAD; this is not necessary after PTA, which is an intervention to treat PAD. It is imperative to assess for dye allergy before performing PTA. Gag reflex is checked after procedures affecting the throat (e.g., endoscopy, bronchoscopy); the femoral artery is generally the access site for PTA.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings would the nurse expect to note as confirming this diagnosis? Select all that apply. 1. Increase in pH 2.Comatose state 3.Deep, rapid breathing 4.Decreased urine output 5.Elevated blood glucose level 6.Low plasma bicarbonate level

3, 5, 6. In DKA, the arterial pH is lower than 7.35, plasma bicarbonate is lower than 15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The client would be experiencing polyuria, and Kussmaul's respirations (deep and rapid breathing pattern) would be present. A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's fasting serum glucose level is normal if which value is noted? A. 110 mg/dL B. 120 mg/dL C. 130 mg/dL D. 140 mg/dL

A. The normal fasting blood glucose is 70 to 110 mg/dL in the adult client. Options 2, 3, and 4 indicate elevated fasting serum glucose levels.

In teaching a client about skin cancer prevention, which instruction does the nurse include? A. "Avoid sun exposure between 11 a.m. and 3 p.m." B. "Examine your skin quarterly for possible cancerous or precancerous lesions." C. "Wear transparent clothing to protect your skin from the sun." D. "If you feel you must tan, use a tanning bed."

A. The sun's rays are strongest between 11 a.m. and 3 p.m. and can cause more damage during this time. Skin should be examined at least monthly. Opaque clothing should be worn to protect the skin from the sun. The rays in tanning beds are just as harmful to skin as the sun's rays and should be avoided.

During a full body admission assessment, you note the patient has a stage III pressure ulcer. How would you document the appearance of the wound?* A. Area is red and does not blanch. B. Full-thickness skin loss to dermis and subcutaneous tissues. C. Partial thickness of dermis with shallow open ulcer. D. Full thickness with bone and tendon visible.

B.

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? A. Inflammation B. Serous drainage C. Pain at a pin site D. Purulent drainage

B. A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported to the health care provider.

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention? A.First B. Second C.Third D. Mixed

B. Second-intention healing is characterized by a cavity-like defect. This requires gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss. First-intention healing is characterized in a wound without tissue loss that can be easily closed and dead space eliminated. Third-intention healing is characterized by delayed primary closure. Wounds with a high risk for infection may be intentionally left open for several days while the wound is débrided and inflammation subsides. There is no such thing as mixed-intention healing.

Which sign/symptom is essential for the nurse to report to the provider when caring for a client with Raynaud's phenomenon? A. Nifedipine (Procardia) administration caused the blood pressure to change from 134/76 to 110/68 mm Hg. B. The client's extremity became white, then red temporarily. C. The affected extremity becomes purple and cold. D. The client states that the digits are painful when they are white.

C. Cold, mottled extremities are indicative of occlusion, which could lead to gangrene. Vasodilating drugs are administered as treatment and may lower the blood pressure; this is not a significant drop. In severe cases, the attack lasts longer, and gangrene of the digits can occur. Pain, numbness, and cold are typical findings in Raynaud's phenomenon.

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (Select all that apply.) A. Hypertension B. Tachycardia C. Bounding right pedal pulses D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg

D, E, F. Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion. Hypertension presents risk for atherosclerosis, but not for acute arterial occlusion. The pulse rate does not indicate occlusion, but rather quality. Absence of pulse, rather than bounding pulse, is a symptom of acute arterial occlusion.

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign, if exhibited in the client, would indicate hyperglycemia? A. Polyuria B. Diaphoresis C. Hypertension D. Increased pulse rate

A. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Options 2, 3, and 4 are not signs of hyperglycemia

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply. 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3 & 6. Hypoglycemia is defined as a blood glucose level less than 70 mg/dL. Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; rapid-releasing glucose is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, and the blood glucose level is retested in 15 minutes; if the reading remains low, additional glucose is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. Encouraging the child to ambulate and administering regular insulin would result in a lowered blood glucose level. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention.

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply.) A. Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL B. Smoking C. Aspirin (acetylsalicylic acid [ASA]) consumption D. Type 2 diabetes E. Vegetarian diet

A, B, D. Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), the client is advised to modify diet and exercise. Smoking is a modifiable risk factor and should be avoided or terminated, and diabetes is a risk factor for atherosclerotic disease. ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease to prevent platelet adhesion. A diet high in whole grains, fruits, and vegetables is desirable to prevent atherosclerosis; vegetarians usually consume fruits, vegetables, and nonanimal sources of protein.

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? A. Reproducible leg pain with exercise B. Unilateral swelling of affected leg C. Decreased pain when legs are elevated D. Pulse oximetry reading of 90%

A. Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin; PAD results from atherosclerotic occlusion of peripheral arteries.

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? A. Fruity breath odor and decreasing level of consciousness B. Sweating and tremors C. Hunger and hypertension D. Cold, clammy skin and irritability

A. Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold clammy skin, irritability, sweating, and tremors all are signs of hypoglycemia.

A client with a foot ulcer says, "I feel helpless." What is the nurse's best response? A. Encourages participation in care of the wound B. Encourages visitors C. Says, "I know how you feel" D. Assures the client that it will be all right

A. Encouraging participation in wound care gives the client a sense of autonomy. Encouraging visitors is not the best suggestion for this client. By telling the client that he or she understands the client's feelings, the nurse not only fails to address the underlying issue but also is patronizing. Assuring the client that everything will be all right not only fails to address the underlying issue, but also may be untrue.

The nurse is developing a teaching plan for a client diagnosed with methicillin-resistant Staphylococcus aureus infection. The nurse plans to include which instruction in the client's teaching plan? A. Take daily tub baths using a mild soap. B. The infected area should be covered with a clean, dry bandage. C. Wash the infected areas first, then wash the uninfected areas. D. Use bath sponges or puffs when bathing.

B. The infected area should be covered with a clean, dry bandage to prevent the spread of infection. The client should shower rather than take a tub bath, using an antibacterial soap. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection. Bath sponges or puffs should be avoided because they cannot be laundered; washcloths should be used only once before laundering.

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which should the nurse specifically observe in the postoperative period? A. Hemorrhage B. Edema of the residual limb C. Slight redness of the incision D. Separation of the wound edges

D. Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative edema of the residual limb and hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as it is dry and intact.

A client with diabetes mellitus is being discharged following treatment for hyperglycemic hyperosmolar state (HHS) precipitated by acute illness. The client tells the nurse, "will call the health care provider (HCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? A.The client needs immediate education before discharge. B.The client requires follow-up teaching regarding the administration of oral antidiabetics. C.The client's statement is inaccurate, and he or she should be scheduled for outpatient diabetic counseling. D.The client's statement is inaccurate, and he or she should be scheduled for educational home health visits.

A. If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the HCP should be notified. The client's statement in this question indicates a need for immediate education to prevent HHNS, a life-threatening emergency. Although all other options may be true, the most appropriate analysis is that the client requires immediate education.

The nursing instructor reviews instructions with the nursing student on caring for an older adult client with a pressure ulcer. What action by the nursing student indicates a need for further instruction about proper skin care for this client? A. Massages bony prominences B. Avoids reddened areas C. Re-positions the client every 1 to 2 hours D. Uses a moisturizing lotion

A. Massaging bony prominences should be avoided in older adult clients because they are at high risk for skin tears. Reddened areas should not be directly massaged because this can damage capillary beds and increase tissue necrosis. The client should be re-positioned at least every 1 to 2 hours to prevent ulcer extension and the generation of additional pressure ulcers. Using a moisturizing lotion is appropriate.

You are assigned five patients on your nursing unit. Which patient is at most risk for pressure ulcers?* A. A 72 year old female weighing 82 lbs with stress incontinence and dementia. B. A 90 year old male with Congestive Heart Failure who has 3+ pitting edema in lower extremities. C. A 6 month old with the flu. D. An ambulatory 88 year old with dementia who is admitted with shingles.

A.

The nurse is teaching a client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include? A. Avoiding or reducing skin exposure to sunlight B. Avoiding tanning beds C. Being aware of skin markings and performing skin self-examination D. Wearing SPF 40 sunscreen

A. Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats). Avoiding tanning beds is significant, but is not the most important technique. It is more important to teach about avoiding sunlight because one can be exposed to sunlight daily. Assessing the skin is a secondary prevention. Wearing sunscreen is essential, but reducing overall exposure to the sun is more important.

The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? A. Withdraws the NPH insulin first B. Withdraws the regular insulin first C. Injects air into NPH insulin vial first D. Injects an amount of air equal to the desired dose of insulin into each vial

A. When preparing a mixture of short-acting insulin such as regular insulin with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3, and 4 identify correct actions for preparing NPH and short-acting insulin.

As a home care nurse, you are providing care to a 63 year old male who suffered a massive stroke. He has paralysis on upper and lower extremities. He has a PEG tube with tubing feedings. The patient's daughter provides care to the patient. You notice the patient has a stage I pressure ulcer on the sacral area. What would you NOT include when educating the daughter on preventing further breakdown of the current pressure ulcer and how to prevent other ones from forming?* A. Exercise the extremities actively and passively. B. Turn and re-position the patient every 2 hours. C. Keep the skin moist and layer the sacral area with extra sheet layers. D. Use pillows to elevated bony prominences.

C.

A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL. Which medication should the nurse anticipate to be prescribed for the client? A.Humulin N insulin B.Humulin R insulin C. Glucagon D. Glyburide (DiaBeta)

C. A blood glucose lower that 50 mg/dL is considered to be critically low. Glucagon is used to treat hypoglycemia because it increases blood glucose levels. Humulin N insulin and Humulin R insulin would lower the client's blood glucose and would not be an appropriate treatment for hypoglycemia. Glyburide is an oral hypoglycemic agent used to treat type 2 diabetes mellitus and would not be given to a client with hypoglycemia. Additionally, an oral medication would not be administered to an unconscious client.

During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first? A. Apply a barrier cream. B. Assess the area for skin breakdown. C. Clean the client. D. Place the client in a side-lying position.

C. Cleaning and drying the client to prevent skin breakdown is the first priority for skin protection. Applying a barrier cream, assessing the area, and placing the client in a side-lying position can all be done after the client has been cleaned.

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? A. Obtain a new IV bag. B. Obtain new IV tubing. C. Wipe the spike end of the tubing with Betadine. D.Scrub the spike end of the tubing with an alcohol swab.

B. The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with Betadine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which complication has occurred? A.Infection B. Phlebitis C. Infiltration D. Thrombosis

C. An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness.

What is the best way for the nurse to prevent a client's stage I pressure ulcer from advancing to stage II? A. Massage the reddened areas. B. Pad the ulcer. C. Promote mobility and/or frequent re-positioning. D. Suggest an egg crate mattress.

C. Frequent re-positioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer. Reddened areas should never be massaged. Padding the ulcer may not be appropriate. An egg crate mattress may be suggested but is not the best option.

The emergency department nurse is preparing a plan for initial care of a client with a diagnosis of hyperglycemic hyperosmolar state (HHS). The nurse understands that the hyperglycemia associated with this disorder results from which occurrence? A. Increased use of glucose B. Overproduction of insulin C. Increased production of glucose D. Increased osmotic movement of water

C. Hyperglycemia results from decreased use and increased production of glucose. Increased use of glucose and overproduction of insulin would most likely cause hypoglycemia. Option 4 is incorrect.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A. Red, hard skin B. Serous drainage C. Purulent drainage D. Warm, tender skin

B. Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristic? A. Metastasis is rare. B. It is encapsulated. C. It is highly metastatic. D. It is characterized by local invasion.

C. Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Options 1, 2, and 4 are not characteristics of a melanoma.

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? A. "I will stop taking my insulin if I'm too sick to eat." B. "I will decrease my insulin dose during times of illness." C. "I will adjust my insulin dose according to the level of glucose in my urine." D. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL."

D. During illness, the client should monitor blood glucose levels and should notify the HCP if the level is higher than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings.

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? A. Intact skin B. Full-thickness skin loss C. Exposed bone, tendon, or muscle D. Partial-thickness skin loss of the dermis

D. In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.