A nurse is caring for a 28-year-old male client with type 1 diabetes mellitus in the medical-surgical unit on day 3 of hospitalization. Below are the exhibits to guide your answer:

Exhibits

Select the two findings that require immediate follow-up:

Glucose at 1130

Client report of shakiness

Temperature

Oxygen saturation

Answer and Explanation

Correct Answer : A,B

Choice A rationale: A blood glucose level of 55 mg/dL is critically low, indicating hypoglycemia. Immediate intervention is required to prevent potential complications such as loss of consciousness, seizures, or even death. Hypoglycemia in individuals with type 1 diabetes can be life-threatening and requires prompt treatment with fast-acting carbohydrates to restore normal blood glucose levels.

Choice B rationale: The client's report of shakiness, hunger, cool skin, and diaphoresis are classic symptoms of hypoglycemia. These symptoms correlate with the dangerously low blood glucose level and indicate an urgent need for intervention. Addressing these symptoms quickly can prevent further deterioration of the client's condition.

Choice C rationale: While the slight increase in temperature to 37.8°C (100°F) is noteworthy, it does not necessitate immediate intervention compared to the hypoglycemic event. Monitoring for any signs of infection or other issues is important, but it is not the highest priority in this scenario.

Choice D rationale: An oxygen saturation of 97% on room air is within normal limits and does not require immediate follow-up. There are no signs of respiratory distress or hypoxia that would necessitate urgent intervention in this case.

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Correct Answer is C

Explanation

Choice A rationale

Administering insulin when the breakfast tray arrives may not provide sufficient time for the insulin to take effect before the client begins eating, potentially leading to hyperglycemia.

Choice B rationale

Administering insulin at 07: is too early and may result in hypoglycemia before the client eats breakfast.

Choice C rationale

Administering insulin at 07: allows sufficient time for the insulin to take effect before the client eats breakfast, helping to maintain appropriate blood glucose levels.

Choice D rationale

Administering insulin 30 minutes after breakfast is too late and could result in hyperglycemia since the client would have already consumed carbohydrates.

A. Obtain an ECG. B. Call the Rapid Response Team. C. Administer another nitroglycerin tablet. D. Initiate a peripheral IV.

Correct Answer is C

Explanation

Choice C rationale

Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.

Choice A rationale

Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.

Choice B rationale

Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.

Choice D rationale

Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.

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A nurse is caring for a 28-year-old male client with type 1 diabetes mellitus in the medical-surgical unit on day 3 of hospitalization. Below are the exhibits to guide your answer: Exhibits Select the two findings that require immediate follow-up:

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has diabetes and plans to administer his regular insulin subcutaneously before he eats breakfast at 08:00 am. After checking the client's morning glucose level, which of the following actions should the nurse take?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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A nurse is caring for a 28-year-old male client with type 1 diabetes mellitus in the medical-surgical unit on day 3 of hospitalization. Below are the exhibits to guide your answer:

Exhibits

Select the two findings that require immediate follow-up: