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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Since the patient's blood glucose level is less than 70 mg/dL and they are symptomatic, the first step is to administer 1 mg Glucagon IM. This will help increase the patient's blood glucose level quickly.
After administering Glucagon, the nurse should then call the MD to report the low blood glucose level and discuss any necessary adjustments to the patient's insulin regimen. It is important to note that in this situation, administering Humalog insulin would further lower the patient's blood glucose level and could worsen their symptoms. Encouraging the patient to eat their meal is also important, but it should be done after the administration of Glucagon to help maintain their blood glucose level.
Correct Answer is D
Explanation
Cushing syndrome is caused by excessive cortisol production by the adrenal glands, which can result in weight gain and redistribution of fat to the abdomen, giving it a characteristic rounded appearance.
The other options mentioned in the question are not typically associated with Cushing syndrome. Chronically low blood pressure is not typically seen in Cushing syndrome, as cortisol is a hormone that can raise blood pressure. A bronzed appearance of the skin is more commonly seen in conditions like Addison's disease, where there is a deficiency of cortisol. Decreased axillary and pubic hair is not a common finding in Cushing syndrome, although excessive hair growth (hirsutism) may occur due to the excess of androgens produced by the adrenal glands.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today