A nurse is caring for a cent who has diabetes mellitus, type 1 Day 3 of hospital
0700
Temperature 37.3°C (981) Boot
Heart rate 121
118/62 mm Hg Temperature 30.8°
Be pressure 104mm Hg 0730
Fingerstick blood glucose, fasting 110 mg/dl. (74 to 106 mg/dL) NPH insulin 40 units subcutaneous administered into abdomen
0830
Client reports nausea with emesis: vomited morning meal 1130
Client reports feeling shaky, hungry, skin cool and diaphoretic Fingerstick blood glucose 55 mg/dL
HbA1c 8.01% (less than 7% greater than 129%)
Select the findings that require immediate follow up
Glucose at 1130
Client report of shakiness
Temperature
Oxygen saturation
Heart rate
HbA1c
Correct Answer : A,B,E
A. Glucose at 1130 - A fingerstick blood glucose level of 55 mg/dL indicates hypoglycemia and requires attention. This has to be addressed to prevent complications.
B. Client report of shakiness - Shakiness, hunger, cool skin, and diaphoresis are classic symptoms of hypoglycemia, which requires immediate intervention to prevent further deterioration.
C. Temperature - While changes in temperature may indicate infection or other issues, the client's symptoms of hypoglycemia are more urgent.
D. Oxygen saturation - While oxygen saturation is important, it is not typically affected in hypoglycemic episodes and is therefore not the priority in this case.
E. Heart rate - Tachycardia is a common symptom of hypoglycemia and should be addressed immediately
F. HbA1c - HbA1c reflects long-term blood glucose control and does not require immediate follow-up in this acute situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While fats are an essential part of the diet, they should not provide the majority of calories, especially in a diabetic diet.
B. While protein is important, it should not be the main source of calories in the diet for someone with diabetes.
C. Complex carbohydrates, such as whole grains, fruits, and vegetables, should provide the majority of calories in a diabetic diet as they have a lesser impact on blood sugar levels compared to simple sugars.
D. Simple sugars should be limited in a diabetic diet as they can cause rapid spikes in blood sugar levels.
Correct Answer is D
Explanation
A. Atorvastatin is a statin medication used to lower cholesterol levels. It does not typically cause glucose intolerance.
B. Guaifenesin is an expectorant used to help loosen mucus in the airways. It does not typically cause glucose intolerance.
C. Ranitidine is a histamine-2 blocker used to reduce stomach acid production. It does not typically cause glucose intolerance.
D. Prednisone is a corticosteroid medication used to reduce inflammation. Corticosteroids like prednisone can cause glucose intolerance by increasing blood sugar levels.
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