A nurse is caring for a 72-year-old client who has type 1 diabetes mellitus.
Select the 3 findings that require immediate follow-up.
Glucose at 1130
Client report of shakiness
Temperature
Heart rate
SPO2
HbA1c
Correct Answer : A,B,D
A. The fingerstick blood glucose level of 55 mg/dL at 1130 indicates hypoglycemia, which requires immediate attention to prevent further complications such as loss of consciousness or severe symptoms.
B. The client's report of shakiness, hunger, and cool, diaphoretic skin are signs of hypoglycemia, especially given the low blood glucose level. This requires prompt intervention to manage the blood glucose level.
C. The temperature of 37.8 °C (100 °F) is slightly elevated but does not require immediate follow-up unless there are other symptoms of infection or significant changes.
D. The elevated heart rate of 118/min could indicate an underlying issue such as dehydration, hypoglycemia, or infection. It requires further evaluation in the context of other findings.
E. The SpO2 of 95% on room air is within an acceptable range and does not require immediate follow-up unless there are other signs of respiratory distress or worsening condition.
F. The HbA1c of 8.01% reflects long-term glucose control but is not an immediate concern for follow-up in the acute setting. It is important for overall management but not an urgent issue for this particular scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Avoiding crowded places is a precaution related to general health and infection control but is not specifically linked to internal radiation therapy.
B. Avoiding fresh fruits and vegetables is not required for internal radiation therapy. Dietary restrictions are not typically necessary unless specified by the healthcare provider.
C. For internal radiation therapy, maintaining distance from others, typically around 6 feet, is important to minimize radiation exposure to others. This safety measure helps reduce the risk of radiation exposure to family members and visitors.
D. Radiation tattoo markings are used to ensure proper placement of the radiation source and should not be washed off. However, this precaution does not directly relate to safety around radiation exposure.
Correct Answer is C
Explanation
A. Inserting a new indwelling urinary catheter could introduce new pathogens and increase the risk of infection rather than reduce it. Indwelling catheters are a known risk factor for urinary tract infections and should be avoided if possible.
B. Collecting blood cultures is an important diagnostic step, especially if sepsis is suspected. However, this action alone does not directly reduce the risk of septic shock. It is a part of the process but not the most immediate intervention.
C. Initiating intravenous (IV) antibiotics is the most critical intervention to reduce the risk of septic shock. Prompt administration of antibiotics can help control the infection before it progresses to sepsis, making this the priority action.
D. Obtaining placement of an intravenous access for fluid administration is necessary for managing sepsis or septic shock, but the first step should be administering antibiotics to treat the infection causing the sepsis. Fluid administration supports blood pressure and circulation but does not directly address the underlying infection.
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