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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View Related questions
Correct Answer is C
Explanation
Choice A rationale
Metabolic acidosis is incorrect. Metabolic acidosis is characterized by a low pH and low HCO₃ levels. In this case, the HCO₃ level is normal, which rules out metabolic acidosis.
Choice B rationale
Metabolic alkalosis is incorrect. Metabolic alkalosis is characterized by a high pH and high HCO₃ levels. In this case, the pH is low, and the HCO₃ level is normal, which rules out metabolic alkalosis.
Choice C rationale
Respiratory acidosis is correct. Respiratory acidosis is characterized by a low pH and high PaCO₂ levels. In this case, the pH is 7.24 (low), and the PaCO₂ is 53 (high), indicating respiratory acidosis. This condition occurs when there is an accumulation of CO₂ in the blood due to inadequate ventilation.
Choice D rationale
Respiratory alkalosis is incorrect. Respiratory alkalosis is characterized by a high pH and low PaCO₂ levels. In this case, the pH is low, and the PaCO₂ is high, which rules out respiratory alkalosis.
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Monitoring the puncture site for hematoma is crucial because a hematoma can indicate bleeding at the puncture site, which can lead to complications such as infection or nerve damage. Hematomas can also cause increased intracranial pressure, which can be dangerous for the patient. Therefore, it is essential to monitor the site closely to ensure that any signs of bleeding are detected early and managed appropriately.
Choice B rationale
Elevating the client’s head of bed is incorrect because it can increase the risk of cerebrospinal fluid (CSF) leakage from the puncture site. After a lumbar puncture, it is recommended to keep the patient in a flat position for several hours to reduce the risk of post-lumbar puncture headache and to allow the puncture site to heal properly. Elevating the head of the bed too soon can disrupt this process and lead to complications.
Choice C rationale
Inserting a urinary catheter is incorrect because it is not a standard procedure following a lumbar puncture. The primary focus after a lumbar puncture is to monitor for complications related to the procedure itself, such as bleeding, infection, or CSF leakage. Inserting a urinary catheter is not necessary unless there is a specific indication for it, such as urinary retention or other urological issues.
Choice D rationale
Encouraging fluid intake is correct because it helps to replenish the CSF that was removed during the lumbar puncture. Increased fluid intake can also help to reduce the risk of post- lumbar puncture headache, which is a common complication. Hydration is important for overall recovery and helps to maintain normal bodily functions.
Choice E rationale
Applying a cervical collar to the client is incorrect because it is not related to the care of a lumbar puncture site. A cervical collar is typically used for patients with neck injuries or conditions affecting the cervical spine. It has no role in the management of a lumbar puncture site and would not provide any benefit in this context.