The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching?

Correct Answer: D

Rationale: The correct answer is D. This statement indicates a need for additional teaching because it shows a lack of understanding about diabetes complications. Here's the rationale: 1. Diabetes can lead to complications even if the patient doesn't need insulin. 2. Complications like heart disease, neuropathy, and kidney damage can still occur in type 2 diabetes. 3. Believing that not needing insulin means no complications is a misconception. 4. Patients with type 2 diabetes need to manage their condition carefully to prevent complications. 5. Therefore, educating the patient about potential complications is crucial for their overall health.

Correct Answer: C

Rationale: The correct answer is C: Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery. Rationale: 1. Administering insulin falls under the scope of practice for an LPN/LVN. 2. Administering lispro insulin before surgery helps maintain the patient's blood glucose within a safe range during the procedure. 3. LPN/LVNs are trained to administer medications safely and accurately. Summary: A: Communication with the circulating nurse requires critical thinking and interpretation, which may be beyond the scope of an LPN/LVN. B: Discussing the reason for insulin therapy involves patient education and interpretation, which are typically responsibilities of a registered nurse. D: Planning strategies to prevent hypoglycemia or hyperglycemia requires higher-level critical thinking and assessment skills, usually performed by a registered nurse.

Correct Answer: D

Rationale: The correct answer is D: Decrease in capillary refill time. Administering 0.9% sodium chloride helps to increase blood volume and improve tissue perfusion, leading to a decrease in capillary refill time. This improvement indicates that the treatment was successful in addressing the fluid volume deficit. A: Increase in hematocrit would not be an immediate indication of the success of fluid resuscitation as it may take time for the hematocrit levels to reflect changes in blood volume. B: Increase in respiratory rate could indicate respiratory distress or other issues not related to the effectiveness of fluid resuscitation. C: Decrease in heart rate could be due to various factors and may not directly correlate with the success of fluid replacement therapy. In summary, the most immediate and direct indicator of successful fluid resuscitation in this scenario is a decrease in capillary refill time.

Correct Answer: B

Rationale: The correct answer is B: Wipe the top of the formula can with alcohol. This is the first action the nurse should take because it ensures the cleanliness and sterility of the formula before administering it to the client through the NG tube, reducing the risk of contamination and infection. A: Making sure the enteral formula is at room temperature is important but not the first action to take. C: Rinsing the feeding bag with water between feedings is not necessary for every feeding and does not address the immediate need to ensure the cleanliness of the formula. D: Instructing the client to keep the head of the bed elevated is important for preventing aspiration but is not the first action to take in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Hydrocolloid dressing. For a stage 2 pressure injury, a hydrocolloid dressing is ideal as it maintains a moist environment to promote healing, absorbs excess exudate, and provides a barrier against bacteria. Transparent dressings (B) are more suitable for superficial wounds. Gauze dressings (C) may adhere to the wound bed and cause trauma upon removal. Alginate dressings (D) are better for wounds with heavy exudate, not typically seen in stage 2 pressure injuries.