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 ["B","C","D","E"]
Explanation
A. Sustaining hyperglycemia is not recommended. Instead, blood glucose levels should be controlled to prevent complications.
B. Smoking cessation is important in reducing the risk of complications such as cardiovascular disease, which is already increased in individuals with diabetes.
C. Maintaining optimal blood pressure is crucial for preventing kidney damage, which is a common complication of diabetes.
D. Reducing cholesterol and saturated fat intake helps in managing cardiovascular risk factors, which are elevated in individuals with diabetes.
E. Increasing physical activity and daily exercise helps in improving insulin sensitivity and managing blood glucose levels.
Correct Answer is ["A","B"]
Explanation
A. Monitoring abdominal girth is important in clients with cirrhosis to assess for ascites, which is a common complication. Changes in abdominal girth can indicate fluid accumulation.
B. Implementing a low-sodium diet is important in managing cirrhosis and preventing complications such as ascites and fluid retention.
C. Administering furosemide may exacerbate electrolyte imbalances in clients with cirrhosis and is not typically indicated unless specifically prescribed by the healthcare provider for managing fluid retention.
D. Administering warfarin may increase the risk of bleeding in clients with cirrhosis due to
impaired liver function and coagulopathy. Warfarin use in cirrhosis requires careful monitoring and is not typically a standard treatment unless indicated for specific conditions such as
thrombosis.
E. Encouraging eating raw or undercooked shellfish, fish, and meat is contraindicated in clients with liver disease due to the risk of bacterial and parasitic infections, which can lead to further complications.
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