A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?
Assess the client's oxygen saturation level.
Determine the client's current glucose level
Give the client one-half cup of fruit juice.
Give the client skim milk and crackers.
The Correct Answer is B
A. While oxygen saturation is important, it's not the priority in this situation. The client's symptoms strongly suggest hypoglycemia.
B. The client's symptoms of diaphoresis, rapid heartbeat, and shakiness are classic signs of hypoglycemia. Therefore, the first action should be to confirm this diagnosis by checking the blood glucose level.
C. Administering glucose before confirming hypoglycemia can be dangerous. If the client is hyperglycemic, giving them sugar will worsen their condition.
D. Providing food without confirming hypoglycemia is not appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A decreased pleural effusion on a chest x-ray is generally a positive outcome following a thoracentesis. It indicates that the procedure was successful in removing the excess fluid. This finding does not warrant immediate intervention and is expected after the procedure.
B. The pH of 7.35 indicates acidosis (normal range is 7.35 to 7.45). The PaCO₂ is on the lower end of normal, suggesting that if there is an acid-base imbalance, it might be metabolic or mixed. The HCO₃⁻ is within normal limits, indicating no metabolic component. The PaO₂ is slightly below the normal range (80-100 mm Hg), which could be a concern but is not critically low.
C. Asymmetrical chest wall expansion can indicate a complication such as pneumothorax (air in the pleural space), which could occur as a complication of thoracentesis. This finding warrants immediate intervention because it may signify a serious issue that requires prompt attention, such as the need for a chest tube or further evaluation.
D. Pain at the insertion site is expected following a thoracentesis and is generally not an urgent concern unless it is severe or associated with other symptoms like fever, difficulty breathing, or signs of infection. This type of pain is usually managed with analgesics and does not typically require immediate intervention unless accompanied by more serious symptoms.
Correct Answer is B
Explanation
A. This is a valid nursing problem and directly related to the client's condition. However, while fatigue is a significant concern, it is often a symptom of other underlying issues.
B. This is the highest priority nursing problem. Pain is a primary symptom of acute RA exacerbation and significantly impacts the client's quality of life, mobility, and overall well-being. Addressing pain is crucial for immediate comfort and to facilitate other interventions.
C. This is also a valid nursing problem, directly linked to the client's symptoms. However, it is a consequence of the pain, not the primary issue. Addressing the pain will improve mobility.
D. This is a potential long-term concern but not the highest priority at this acute stage. The client's immediate needs related to pain and mobility are more pressing.
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