A 46-year-old woman who was diagnosed with an upper respiratory infection yesterday and prescribed an antibiotic presents to the ED reporting. "l just don't feel right." The client has a history of diabetes mellitus type 2, hypertension, peripheral neuropathy, vascular disease, and retinopathy. On admission to a medical-surgical unit, the nurse implements a plan of care to prevent complications and maintain client safety while in the hospital.

Indicate which nursing action is appropriate to prevent complications of diabetes mellitus and maintain client safety while in the hospital.

Administer angiotensin-converting enzyme (ACE) inhibitor as prescribed.

Administer intravenous 5%D/NS at 200 mL/hr.

Administer I mg glucagon 1M PRN for blood glucose 70-90 mg/dL (3.9-5.0 mmol/L).

Ensure the path to the bathroom is well-lit.

Teach the client to rise slowly from the bed.

Coordinate meal-time insulin with food delivery and consumption.

Answer and Explanation

Correct Answer : D,F,G

Option A is incorrect because administering an ACE inhibitor may be a part of the patient's regular medication regimen, but it is not specific to preventing complications of diabetes mellitus while in the hospital.
Option b is incorrect because administering intravenous ﬂuids at a high rate may result in ﬂuid overload, electrolyte imbalances, and other complications, which may not be appropriate for this patient.
Option c is incorrect because administering glucagon is not a preventative measure, but rather an intervention for treating hypoglycemia.
Option d is correct because ensuring a well-lit path to the bathroom is important for fall prevention, but it does not directly address the prevention of complications of diabetes mellitus.
Option e is incorrect because encouraging the client to drink sugar-free liquids is a general recommendation for maintaining hydration and may not be specific to preventing complications of diabetes mellitus.
Option f is correct because teaching the client to rise slowly from the bed is important for preventing orthostatic hypotension, but it does not directly address the prevention of complications of diabetes mellitus.
Option g is correct because Patients with diabetes mellitus are at risk for hypoglycemia when taking insulin or oral hypoglycemic agents. Proper coordination of meal-time insulin with food delivery and consumption can help prevent hypoglycemia or hyperglycemia. This includes ensuring that the patient receives insulin at the appropriate time in relation to meals and monitoring blood glucose levels regularly.

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Correct Answer is B

Explanation

IV ﬂuids are not typically used as a treatment for UTIs (urinary tract infections) as they do not directly address the infection itself. The main reason for administering IV ﬂuids to a patient with a UTI would be to ensure adequate hydration, especially if the patient is experiencing fever or other symptoms of dehydration. Adequate hydration can also help improve the efficacy of antibiotics in treating the infection by ensuring that the urinary system is properly functioning and able to ﬂush out bacteria.

Therefore, option b would be the closest answer as IV ﬂuids may be given to facilitate the administration of IV antibiotics. However, it is important to note that antibiotics are the primary treatment for UTIs, and IV ﬂuids are usually given as a supportive measure to ensure the patient's overall well-being. Flushing bacteria from the urinary tract or diluting bacteria are not considered primary rationales for administering IV ﬂuids in a patient with a UTI. Relief of pain and discomfort may be managed with pain medication, but this is not the primary reason for IV ﬂuid administration.

A. Restricts oral intake. B. Monitor blood pressure every 4 hours. C. Administer SQ insulin as prescribed. D. Maintain a patent airway.

Correct Answer is D

Explanation

A decrease in the level of consciousness is a serious sign and could be an indication of worsening conditions. It is essential for the nurse to ensure that the patient's airway is open and clear, as a compromised airway can lead to hypoxia and a further decrease in consciousness. Therefore, maintaining a patent airway should be the nurse's priority action in this situation.

While monitoring blood pressure and restricting oral intake may be important interventions in certain situations, they are not the priority actions in this scenario. Administering SQ insulin may not be necessary for a patient with hypothyroidism and acute appendicitis.

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Naxlex Comprehensive Predictor Exams

What is the rational for IV ﬂuids in a patient with a UT!?

Correct Answer is B

Explanation

A nurse assesses a patient with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the patient's level of consciousness has decreased. What action does the nurse perform?

Correct Answer is D

Explanation

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Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine?

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