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
A complete blood count (CBC) can provide general information about the body's response to an MI, such as white blood cell count, but it is not definitive for diagnosing an MI.
Choice B rationale
A lipid profile measures cholesterol levels and helps assess cardiovascular risk, but it is not useful for diagnosing an acute MI.
Choice C rationale
An electrocardiogram (ECG) is essential for diagnosing an MI as it shows the heart's electrical activity and can indicate ischemia or infarction.
Choice D rationale
Troponin levels are the most specific and sensitive markers for myocardial infarction. Elevated troponin levels confirm heart muscle damage due to an MI, making it the definitive test.
Correct Answer is B
Explanation
Choice A rationale
Notifying the healthcare provider is necessary, but assessing the client's condition comes first to provide relevant information.
Choice B rationale
Assessing the client's vital signs and telemetry monitor is the first step to determine the cause of chest pain and ensure it is not due to a life-threatening issue such as myocardial infarction.
Choice C rationale
Encouraging the client to take deep breaths can be helpful but is not the first priority. It addresses pain related to breathing but not the underlying cause.
Choice D rationale
Administering pain medication is important, but only after determining the cause of the chest pain and ruling out serious complications.
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