A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

Acetone breath odor

Polydipsia

Inability to concentrate

Diaphoresis

Tremors

Answer and Explanation

Correct Answer : C,D,E

Rationale:
A. Acetone breath odor: A fruity or acetone breath odor occurs when the body produces ketones due to fat breakdown in hyperglycemia or diabetic ketoacidosis (DKA). This finding is not associated with hypoglycemia but rather prolonged high blood glucose levels.

B. Polydipsia: Excessive thirst (polydipsia) is a sign of hyperglycemia because the kidneys attempt to excrete excess glucose, leading to dehydration. It does not occur during hypoglycemia, when blood sugar levels are abnormally low.

C. Inability to concentrate: Low blood glucose deprives the brain of its primary energy source, leading to confusion, irritability, and difficulty concentrating. These neuroglycopenic symptoms are hallmark signs of hypoglycemia and can progress to altered consciousness if untreated.

D. Diaphoresis: Sweating is a classic adrenergic response to hypoglycemia as the body releases epinephrine to raise blood glucose levels. It serves as an early warning sign, prompting immediate carbohydrate intake to prevent further decline in blood sugar.

E. Tremors: Tremors occur due to increased sympathetic nervous system activity during hypoglycemia. The body responds to falling glucose by releasing catecholamines, which stimulate muscle activity and cause shaking or trembling sensations.

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Correct Answer is A

Explanation

Rationale:
A. Gently push the syringe plunger to administer medication: Medications given via NG tube should be administered slowly and gently using a syringe to avoid tube damage, aspiration, or sudden changes in gastric pressure. This technique ensures safe and effective delivery of the medication.

B. Dissolve the medications together: Mixing multiple medications can cause chemical interactions or precipitation, which can block the NG tube or reduce medication efficacy. Each medication should be dissolved and administered separately.

C. Flush the NG tube with 5 mL of cold tap water after administration: Flushing is necessary to maintain tube patency, but 5 mL is insufficient for continuous feedings. Typically, 15–30 mL of warm or room-temperature water is used to prevent tube occlusion.

D. Add medication directly to the enteral feeding: Adding medication to the feeding can alter the composition, affect absorption, and create a risk for tube blockage. Medications should be given separately with flushing before and after administration.

A. Change the drainage tubing every 48 hr. B. Irrigate the drain to maintain suction. C. Observe for drainage flow through the tubing. D. Remove the drain if output from the drain increases.

Correct Answer is C

Explanation

Rationale:
A. Change the drainage tubing every 48 hr: Routine changing of drainage tubing is not recommended unless it becomes contaminated or occluded. Frequent manipulation increases the risk of infection and compromises the sterile system.

B. Irrigate the drain to maintain suction: Irrigating a closed wound drainage system can introduce pathogens and disrupt the vacuum, increasing the risk of infection. Closed systems are designed to maintain suction without routine irrigation.

C. Observe for drainage flow through the tubing: Monitoring the amount, color, and consistency of drainage is essential to assess wound healing and detect complications such as infection or hemorrhage. Observing flow ensures the system is functioning properly and provides critical data for clinical decisions.

D. Remove the drain if output from the drain increases: Increased output can indicate ongoing bleeding or infection and should be reported to the provider. Premature removal of the drain in this situation could lead to fluid accumulation, wound dehiscence, or infection.

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A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

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Correct Answer is C

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