a patient suffering from hyperglycemia would be experiencing

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. A patient suffering from hyperglycemia would be experiencing:

A. Low blood sugar
B. High blood sugar
C. Normal blood sugar
D. None of the above

Correct answer: B

Rationale: Hyperglycemia is a condition characterized by high blood sugar levels. In this state, there is an excess of glucose in the bloodstream. Patients with hyperglycemia are often diagnosed with diabetes. The term 'hyperglycemia' specifically refers to elevated blood sugar levels. Therefore, the correct answer is 'High blood sugar.' Choices A, C, and D are incorrect because hyperglycemia indicates elevated blood sugar levels and not low or normal levels.

2. When is a physician likely to assess turgor?

A. When iron deficiency is suspected.
B. When heart and lung issues are suspected.
C. When dehydration is suspected.
D. None of the above.

Correct answer: C

Rationale: Skin turgor is assessed when dehydration is suspected. To evaluate skin turgor, a physician pinches the skin and observes how quickly it returns to its normal position. If the skin stays folded for an extended period, it indicates dehydration. Assessing turgor helps determine a patient's hydration status. Choice A is incorrect because skin turgor is not used to assess iron deficiency. Choice B is incorrect as turgor is not related to heart and lung issues, but rather hydration status. Choice D is incorrect as turgor assessment is relevant when dehydration is suspected.

3. A client has applied a cold pack to their arm to help decrease swelling and inflammation after an injury. Which of the following signs indicates that the cold pack should be removed?

A. The skin on the arm appears mottled
B. The cold pack has been in place for 10 minutes
C. The client complains of feeling nauseated
D. The capillary refill in the area distal to the arm is 2 seconds

Correct answer: A

Rationale: When using a cold pack for therapeutic purposes, it is essential to monitor the site to prevent tissue damage. Prolonged use of cold therapy can lead to pale, mottled skin with a bluish appearance. This change in skin color indicates poor circulation, and the cold pack should be removed immediately to prevent tissue injury. Choices B, C, and D are incorrect because the duration of cold pack application, client complaints of nausea, and capillary refill time do not specifically indicate the need for the cold pack to be removed due to potential tissue damage.

4. To collect timely, specific information, the nurse is most likely to ask which of the following questions?

A. Would you describe what you are feeling?
B. How are you today?
C. What would you like to talk about?
D. Where does it hurt?

Correct answer: A

Rationale: The correct answer is, 'Would you describe what you are feeling?' This open-ended question prompts the patient to provide subjective data, offering specific information about their current health status and human responses. This information can help identify actual or potential health issues. Choices B and C are more likely to yield general, nonspecific information. Choice D may lead to a brief response or nonverbal indication of pain location. A more effective approach to gather specific information about pain would be to ask, 'Can you describe any pain you are experiencing?'

5. Specific gravity in urinalysis:

A. compares the concentration of urine to that of distilled water
B. is useless when the patient is dehydrated
C. can only be measured using a refractometer
D. None of the above

Correct answer: A

Rationale: Specific gravity in urinalysis measures the concentration of solutes in urine compared to that of distilled water. This comparison helps in assessing the kidney's ability to concentrate urine properly. It is a valuable test even in dehydrated patients as it provides insights into renal function. Specific gravity can be measured using various methods, including a refractometer or reagent strips. Normal specific gravity readings of human urine typically range from 1.005 to 1.030. Choice A is correct as it accurately describes the purpose of specific gravity in urinalysis. Choices B and C are incorrect as specific gravity remains relevant in dehydrated patients and can be measured using different techniques, not solely a refractometer.