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:
Select the two findings that require immediate follow-up:
Glucose at 1130
Client report of shakiness
Temperature
Oxygen saturation
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Attaching a wristband indicating the client's allergy is a good practice, but it is not the priority action. The priority is to notify the provider to avoid any potential allergic reactions during the procedure.
Choice B rationale
Notifying the dietary department is not relevant in this context. The priority is to ensure the provider is aware of the allergy to prevent an adverse reaction during the cardiac catheterization.
Choice C rationale
Asking the client about other food allergies is important, but the priority action is to notify the provider immediately to ensure the safety of the client during the procedure.
Choice D rationale
Notifying the provider of the client's allergy is the priority action. This ensures that the provider can take necessary precautions to prevent an allergic reaction during the cardiac catheterization procedure.
Correct Answer is A
Explanation
Choice A rationale
Total parenteral nutrition (TPN) provides essential nutrients intravenously, allowing the bowel to rest and heal, which is important in the management of inflammatory bowel disease (IBD).
Choice B rationale
While reducing inflammation and controlling symptoms are important goals in IBD management, TPN is primarily used to provide nutrition and allow the bowel to rest.
Choice C rationale
Stimulating the bowel is not the purpose of TPN. TPN is used to give the digestive tract a break while ensuring the patient receives necessary nutrients.
Choice D rationale
Preventing malnutrition and promoting weight gain are secondary benefits of TPN, but the primary rationale is to provide nutrients while allowing the bowel to rest and heal.
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