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 D
Explanation
A. Vasopressin does not typically increase the client's heart rate; its primary effect is on the kidneys and urine output.
B. Vasopressin generally increases blood pressure by promoting vasoconstriction, not decreases it.
C. Vasopressin will increase, not decrease, urine specific gravity by reducing urine output and concentrating the urine.
D. Vasopressin acts to decrease urine output by increasing water reabsorption in the kidneys, which helps manage diabetes insipidus.
Correct Answer is C
Explanation
A. Restricting sodium intake is essential in managing ascites and edema in cirrhosis, but it does not directly reduce ammonia levels. Sodium restriction is more related to fluid management rather than ammonia reduction.
B. Administering vitamin K may be necessary for correcting coagulation issues in liver disease, but it does not address the elevated ammonia levels causing encephalopathy.
C. Reducing protein intake is crucial for decreasing ammonia production. In clients with hepatic encephalopathy, proteins are broken down into ammonia, which the impaired liver cannot detoxify effectively, leading to worsened symptoms. Therefore, reducing dietary protein can help lower ammonia levels.
D. Administering diuretics is used to manage fluid retention and ascites in cirrhosis, but it does not directly impact ammonia levels. Diuretics are not the primary intervention for hepatic encephalopathy.
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