A client who has type 2 diabetes mellitus takes metformin 500 mg PO daily for blood glucose control. The client has been NPO since midnight in preparation for general anesthesia and surgery. At 0700 the client's serum glucose level is 250 mg/dL (13.9 mmol/L). Which action should the nurse implement?

Reference Range:

Fasting Blood Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Obtain a prescription for regular insulin SUBQ per sliding scale.

Record the blood glucose results and requisition a repeat test in one hour.

Prepare to initiate a continuous IV infusion of Insulin in normal saline.

Administer the client's daily metformin tablet with a sip of water.

Answer and Explanation

The Correct Answer is A

A. Administering insulin per sliding scale is appropriate for managing elevated blood glucose in a patient who is NPO and cannot take oral hypoglycemics like metformin.

B. Repeating the test in one hour delays necessary treatment and does not address the current hyperglycemia.

C. A continuous IV infusion of insulin is more appropriate for severe hyperglycemia or critical care situations, but obtaining a sliding scale prescription is more routine in this context.

D. Administering metformin with a sip of water could be considered if the provider orders it, but typically, oral hypoglycemics are held when a patient is NPO.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Applying antibiotic ointment is not appropriate for this situation as the issue is likely compromised blood flow, not infection.
B. Checking oxygen saturation is not related to the color change of the stoma.
C. Switching to non-latex supplies is important for clients with latex allergies but is not relevant to the immediate problem.
D. A dark red to bluish color of the stoma suggests compromised blood flow and possible ischemia, which requires immediate medical attention. The nurse should notify the healthcare provider immediately to address this potentially serious complication.

A. "How is this hearing loss interfering with your daily activities of living?" B. "Is this hearing loss accompanied by any loss of balance?" C. "Do you have a history of ear infections?" D. "Have you ever considered being evaluated for a hearing aid?"

Correct Answer is B

Explanation

A. Assessing the impact of hearing loss on daily activities is important but not the immediate follow-up question to understand the nature of the hearing loss.
B. Asking about balance issues is essential because it could indicate an inner ear problem, which often affects both hearing and balance.
C. A history of ear infections could be relevant but is not as immediately necessary for determining the cause of the current symptoms.
D. Considering a hearing aid is a step for management, but determining the nature and cause of the hearing loss is the priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

Correct Answer is D

Explanation

An older adult client reports noticing increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow-up question is best for the nurse to ask?

Correct Answer is B

Explanation

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

The nurse is caring for a client who is taking the mood stabilizer divalproex sodium. Which laboratory value is most important for the nurse to monitor?

A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?