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
Reduced bronchospasm is a beneficial outcome for COPD, but it is not the primary outcome related to gas exchange.
Choice B rationale
Decreased breathlessness is a positive outcome for COPD, but it is not directly related to gas exchange.
Choice C rationale
Increased carbon dioxide retention is a negative outcome and indicates worsening of gas exchange.
Choice D rationale
Improved oxygen saturation levels are a direct and measurable outcome of effective gas exchange and indicate better oxygenation in COPD patients.
Correct Answer is D
Explanation
Choice A rationale
Administering a laxative is not necessary for a CT scan of the abdomen with contrast. Laxatives are typically used for bowel preparation for procedures like colonoscopies.
Choice B rationale
Biguanide medications such as metformin should be held before and after the administration of contrast medium to prevent lactic acidosis, particularly in clients with liver disease.
Choice C rationale
Fasting for 24 hours is not required before a CT scan with contrast medium. Typically, clients are asked to fast for a few hours prior to the procedure.
Choice D rationale
Ensuring the client is adequately hydrated helps to protect kidney function and reduce the risk of contrast-induced nephropathy. Hydration is especially important for clients with a history of liver disease.
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