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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Anuria, or the absence of urine output, occurs in later stages of shock when there is significant renal hypoperfusion. It is not an early indicator of shock.
B. Hypotension is a classic sign of shock, but it generally occurs after compensatory mechanisms have failed. It is not the earliest indicator.
C. A decreased level of consciousness occurs later in the progression of shock due to decreased cerebral perfusion. It is not the earliest sign of shock.
D. Increased respiratory rate is often the earliest indicator of shock. As the body attempts to compensate for decreased oxygen delivery and tissue perfusion, the respiratory rate increases to enhance oxygenation and eliminate excess carbon dioxide. This compensatory mechanism is typically one of the first signs that shock is developing.
Correct Answer is B
Explanation
A. Consulting with a healthcare provider before taking over-the-counter medications is appropriate, as some medications can affect blood glucose levels or interact with diabetes medications.
B. It is crucial for clients with diabetes to continue taking insulin during illness, even if they are unable to eat. Insulin needs may increase due to stress or infection, and not taking insulin could lead to hyperglycemia or diabetic ketoacidosis. Checking blood sugar every 2 hours is correct, but insulin should not be omitted.
C. Calling the doctor if the illness lasts longer than 2 days is a good practice, as prolonged illness can affect diabetes management and may require medical intervention.
D. Calling the doctor if blood sugar is over 250 mg/dL or if there is protein in the urine is appropriate, as these conditions can indicate complications that need medical attention.
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