Saunders NCLEX Questions and anwers correct and verified A+

Saunders NCLEX Questions and anwers correct and verified A+ Saunders NCLEX Questions and anwers correct and verified A+ The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which of the following 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 - correct answer-d. Partial-thickness skin loss of the dermis Rationale: 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. A nurse is preparing a teaching plan for a client with DM regarding proper foot care. Which instruction is included in the plan? a. Soak feet in hot water b. Avoid using a mild soap on the feet c. Apply a moisturizing lotion to dry feet but not between the toes d. Always have a podiatrist cut your toenails; never cut them yourself - correct answer-c. Apply a moisturizing lotion to dry feet but not between the toes Rationale: the client is instructed to use a moisturizing lotion on the feet and to avoid applying the lotion between the toes. The client should be instructed not to soak the feet and should avoid hot water to prevent burns. The client may cut the toenail straight across and even with the toe itself and would consult a podiatrist at the toenails were thick or hard to cut or if vision were poor. The client should be instructed to wash the feet daily with a mild soap. A client newly diagnosed with DM has been stabilized with daily insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and plans to reinforce which of the following concepts? a. Always keep insulin vials refrigerated b. Ketones in the urine signify a need for less insulin c. Increase the amount of insulin before unusual exercise d. Systemically rotate insulin injections within one anatomic site - correct answer-d. Systemically rotate insulin injections within one anatomic site Rationale: insulin doses should not be adjusted nor increased before unusual exercise. If ketones are found in the urine, it possibly may indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, insulin should be administered at room temperature. Injection sites should be rotated systematically within one anatomic site. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in an emergency room. Which finding would a nurse expect to note as confirming this diagnosis? a. Comatose state b. Decreased urine output c. Increased respirations in an increase in pH d. Elevated blood glucose level an low plasma bicarbonate level - correct answer-d. Elevated blood glucose level an low plasma bicarbonate level Rationale: in DKA, the arterial pH is lower than 7.35, plasma bicarbonate is a lower than 15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood in urine. The client would be experiencing polyuria, and Kussmaul's respirations would be present. A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis. In external insulin pump is prescribed for a client with DM in the client ask the nurse about the functioning of the pump. The nurse bases the response on the information that the pump: