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 A

Explanation

A. A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.
B. The client with muscle weakness should use the unaffected hand for daily activities to ensure safety and improve functional outcomes. Using the affected hand may increase the risk of injury.
C. A soft diet and thickened liquids are generally recommended for clients with dysphagia, which is not specifically indicated in the context of muscle weakness due to a stroke.
D. Encouraging the client to complete all ADLs independently may not be feasible or safe due to the muscle weakness. Support and assistance with ADLs are likely needed.

A. Assess for sources of bleeding and provide pressure on wounds B. Limit contact with infected visitors and place in positive pressure isolation C. Administer antiemetics and assess nutrition and hydration status D. Monitor energy levels and begin energy-conserving techniques

Correct Answer is B

Explanation

A. Assessing for sources of bleeding is important in clients with neutropenia, but the highest priority is preventing infection, as the client’s absolute neutrophil count is zero, indicating an extremely high risk for infection.
B. Limiting contact with infected visitors and placing the client in positive pressure isolation is crucial for preventing infections. With a neutrophil count of zero, the client is highly immunocompromised and at a significant risk of infection, making this the highest priority action.
C. Administering antiemetics and assessing nutrition and hydration are important for managing symptoms, but they do not address the immediate risk of infection associated with severe neutropenia.
D. Monitoring energy levels and implementing energy-conserving techniques are important for overall care but do not address the urgent need to protect the client from infections due to their neutropenic status.

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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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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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.