A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records.
ExhibitsComplete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.Answer and Explanation
The Correct Answer is []
Potential Condition: The client’s elevated HbA1c (8.4%) and blood glucose level (235 mg/dL) indicate poorly controlled diabetes mellitus, which is likely leading to their symptoms of fatigue, blurred vision, dizziness, and headache. The client’s history of running out of insulin and glucose strips further supports the diagnosis of Type 1 diabetes mellitus, or possibly poorly controlled Type 2 diabetes mellitus.
Actions to Take:
Teach the client about the signs of hyperglycemia: Given the elevated blood glucose levels and lack of regular monitoring, it is essential to educate the client on recognizing signs of hyperglycemia to prevent complications such as diabetic ketoacidosis.
Assess the client’s feet for sensation: Diabetes can lead to neuropathy, increasing the risk of foot injuries and infections. Regular assessment of foot sensation is vital for early detection and prevention of complications.
Parameters to Monitor:
Fingerstick blood glucose: Frequent monitoring of blood glucose is necessary to assess the effectiveness of the insulin regimen and to make necessary adjustments.
Urinary output: Monitoring urinary output is important because polyuria is a common symptom of hyperglycemia. Decreased urine output may also indicate dehydration or renal impairment, both of which are complications of poorly controlled diabetes.
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Related Questions
Correct Answer is ["4"]
Explanation
To determine the correct dosage of albuterol syrup, the nurse needs to perform a simple calculation. The prescription requires 1.6 mg of albuterol per dose. With the available concentration of 2 mg per 5 mL, the nurse can calculate the volume of syrup needed by setting up a proportion: (2 mg / 5 mL = 1.6 mg / X mL). Solving for X gives us (1.6 mg * 5 mL) / 2 mg, which equals 4 mL.
Correct Answer is D
Explanation
A. A low temperature is not indicative of organ rejection; fever would be more concerning.
B. Weight loss is not a typical sign of acute organ rejection; weight gain due to fluid retention might be observed.
C. Insomnia is not specifically associated with organ rejection.
D. Oliguria (decreased urine output) is a significant sign of possible kidney transplant rejection, as it may indicate impaired kidney function.
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