A nurse is assessing a patient with a history of diabetes and hypertension. The nurse should monitor for which of the following complications?

Correct Answer: A

Rationale: The correct answer is A: Chronic kidney disease (CKD). Patients with diabetes and hypertension are at increased risk for developing CKD due to the damaging effects of high blood sugar and elevated blood pressure on the kidneys. The nurse should monitor for signs and symptoms of kidney dysfunction such as proteinuria, elevated creatinine levels, and decreased glomerular filtration rate. B: Chronic pain is not directly related to the patient's history of diabetes and hypertension. While the patient may experience pain as a result of complications from these conditions, it is not the primary complication to monitor for in this case. C: Hypotension, or low blood pressure, is not a common complication associated with diabetes and hypertension. These conditions typically lead to high blood pressure rather than low blood pressure. D: Sepsis is a serious infection that can occur in any patient, but it is not a direct complication specifically related to diabetes and hypertension. Monitoring for sepsis would be important in a broader context but is not

Correct Answer: A

Rationale: The correct answer is A (3 years old) because the Nipissing District Developmental Screen is specifically designed for children aged 1 month to 6 years to assess their developmental milestones. It focuses on various areas of development appropriate for this age group, such as motor skills, language, social interaction, and cognitive abilities. Using this tool with a 3-year-old child allows for early identification of potential developmental delays or concerns. Incorrect choices: B (16 years old) - The Nipissing District Developmental Screen is not intended for children above 6 years old. C (8 years old with a developmental delay) - The tool is primarily for early screening, not for children already identified with developmental delays. D (Having difficulty with gross motor skills) - While this child may benefit from assessment, the Nipissing Screen is a comprehensive tool for overall development, not just specific skill deficits.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. The priority nursing action for a client experiencing severe chest pain is to administer nitroglycerin to help dilate the blood vessels and improve blood flow to the heart, reducing chest pain. This action helps to address the immediate issue of chest pain and potential heart damage. Administering morphine (B) may be considered if chest pain persists despite nitroglycerin. Administering oxygen (C) can also be helpful but is not the initial priority. Monitoring blood pressure (D) is important but not the most urgent action in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Cover the burn site with a clean, dry dressing. This intervention helps protect the burn from infection, promotes healing, and reduces pain. Ice can further damage the skin. Pain medication may be needed but does not address wound care. Maintaining a sterile dressing is crucial, but covering with a clean, dry dressing is more practical and achievable in most settings.

Correct Answer: B

Rationale: The correct answer is B: Assess vital signs and oxygen saturation levels. This is the priority action because the patient's symptoms suggest a possible cardiac event. Assessing vital signs and oxygen saturation levels can provide crucial information on the patient's condition and help determine the urgency of the situation. Administering pain medication (choice A) should not be done before assessing the patient's vital signs. Having the patient walk around (choice C) could worsen the situation if it is indeed a cardiac event. Ordering an EKG (choice D) is important but should come after assessing vital signs to guide further evaluation and treatment.