A nurse is checking the laboratory results of a client who is at risk for diabetes mellitus. Which of the following laboratory results indicates to the nurse that the client is at risk for diabetes mellitus?
2-hr blood glucose 132 mg/dL.
HbA1c 5.2%.
Casual blood glucose 178 mg/dL.
Fasting blood glucose 155 mg/dL. .
The Correct Answer is D
Choice A rationale
A 2-hour blood glucose level of 132 mg/dL is below the threshold for diabetes diagnosis, which is 200 mg/dL or higher.
Choice B rationale
An HbA1c level of 5.2% is within the normal range. Diabetes is diagnosed with an HbA1c of 6.5% or higher.
Choice C rationale
A casual blood glucose level of 178 mg/dL is elevated but not diagnostic of diabetes. Diabetes is diagnosed with a casual blood glucose level of 200 mg/dL or higher.
Choice D rationale
A fasting blood glucose level of 155 mg/dL is above the threshold for diabetes diagnosis, which is 126 mg/dL or higher. This indicates that the client is at risk for diabetes mellitus.
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Correct Answer is C
Explanation
Choice A rationale
A red and beefy tongue is not a symptom of digoxin toxicity. This symptom is more commonly associated with vitamin B12 deficiency or other nutritional deficiencies.
Choice B rationale
Constipation is not a typical symptom of digoxin toxicity. Digoxin toxicity primarily affects the gastrointestinal system with symptoms such as nausea, vomiting, and diarrhea, rather than causing constipation.
Choice C rationale
Yellow vision, or xanthopsia, is a classic symptom of digoxin toxicity. Digoxin can cause visual disturbances, including seeing halos around lights and a yellow tint to vision, due to its effects on the optic nerve.
Choice D rationale
Gaining weight is not a symptom of digoxin toxicity. Weight gain is more commonly associated with fluid retention in conditions such as heart failure, which digoxin is used to treat.
Correct Answer is D
Explanation
Choice A rationale
Positioning the lower extremities so that they are touching is incorrect because it can lead to adduction of the hip, which increases the risk of dislocation. After a total hip arthroplasty, it is important to maintain proper alignment of the hip joint to prevent dislocation. Keeping the legs apart with the use of an abduction pillow or wedge is recommended to maintain proper alignment and reduce the risk of complications.
Choice B rationale
Ensuring that the client’s heels are touching the bed is incorrect because it can lead to pressure ulcers. After a total hip arthroplasty, it is important to prevent pressure on the heels by using pillows or heel protectors to elevate the heels off the bed. This helps to reduce the risk of pressure ulcers and promotes better circulation to the lower extremities.
Choice C rationale
Instructing the client to avoid movement of the affected leg is incorrect because early mobilization is important for recovery. After a total hip arthroplasty, patients are encouraged to perform gentle exercises and mobilize as soon as possible to prevent complications such as deep vein thrombosis (DVT) and to promote healing. Immobilization can lead to stiffness, muscle atrophy, and other complications.
Choice D rationale
Preventing hip flexion of the affected extremity is correct because excessive hip flexion can increase the risk of dislocation. After a total hip arthroplasty, it is important to avoid positions that involve hip flexion greater than 90 degrees, such as sitting in low chairs or bending forward excessively. Maintaining proper hip precautions helps to reduce the risk of dislocation and promotes a safe recovery.