A nurse is caring for a 72-year-old client who has type 1 diabetes mellitus.

Exhibits

Select the 3 findings that require immediate follow-up.

Glucose at 1130

Client report of shakiness

Temperature

Heart rate

SPO2

HbA1c

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Decreasing the client's oral fluid intake is inappropriate in the postoperative period following a TURP, as adequate hydration is essential to prevent clot formation and maintain catheter patency. Limiting fluids could lead to increased clot formation and obstructed flow.
B. Weighing the client every evening is not a relevant intervention in the immediate postoperative period of TURP. Weight monitoring is more critical for fluid balance in chronic conditions such as heart failure or renal disease, not in the acute setting after TURP.
C. Monitoring urine output every 6 hours is insufficient for a client receiving continuous bladder irrigation. Immediate postoperative care requires more frequent monitoring to detect potential complications such as clot retention or hemorrhage.
D. Reminding the client that he might feel a constant urge to void is essential. Continuous bladder irrigation can cause bladder spasms and a persistent sensation of needing to urinate, which is common after TURP. This helps the client understand and cope with these sensations, reducing anxiety and unnecessary concern.

A. "Tremors, nervousness, and insomnia may indicate your dose is too high." B. "Notify your healthcare provider if you begin to lose weight." C. "This medication will require monitoring for increased risk for bleeding." D. "The medication decreases the overproduction of the thyroid hormone thyroxine."

Correct Answer is A

Explanation

A. Levothyroxine is used to replace thyroid hormone in hypothyroidism. Symptoms like tremors, nervousness, and insomnia can indicate that the dose is too high, suggesting possible hyperthyroidism.
B. Weight loss alone is not a primary indicator for adjusting levothyroxine. It is more important to monitor for symptoms of overdosage, such as those described in option A.
C. Levothyroxine does not increase the risk of bleeding. Monitoring is typically focused on thyroid hormone levels rather than bleeding risks.
D. Levothyroxine increases thyroid hormone levels, not decreases them. It is used to supplement the deficient hormone in hypothyroidism.

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A nurse is caring for a 72-year-old client who has type 1 diabetes mellitus. Exhibits Select the 3 findings that require immediate follow-up.

Nursing Test Bank

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A nurse is caring for a 72-year-old client who has type 1 diabetes mellitus.

Exhibits

Select the 3 findings that require immediate follow-up.