A nurse is contributing to the care plan for a client who has recently been diagnosed with type 2 diabetes mellitus. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Instruct the client to soak his feet daily.

Assist the client in developing an individualized meal plan.

Check the client’s blood glucose level before meals and at bedtime.

Administer an extra dose of insulin if the client’s blood glucose level drops to 50 mg/dl

Answer and Explanation

Correct Answer : B,C

Choice A rationale:

Instructing the client to soak his feet daily is not recommended for individuals with diabetes. Soaking the feet can increase the risk of foot problems, particularly if the person has nerve damage or poor blood flow. It can lead to dry and cracked skin, which can increase the risk of infection. Therefore, this intervention should not be included in the care plan.

Choice B rationale:

Assisting the client in developing an individualized meal plan is a crucial intervention for managing type 2 diabetes. Meal planning is the first step in healthy eating and is especially important for people with diabetes because food directly impacts blood glucose levels. An individualized meal plan considers the person’s goals, tastes, lifestyle, and any medicines they’re taking. Therefore, this intervention should be included in the care plan.

Choice C rationale:

Checking the client’s blood glucose level before meals and at bedtime is an essential part of managing diabetes. Regular monitoring of blood glucose levels can help track the effect of diabetes medicines, understand how diet and exercise affect blood glucose levels, and detect if blood glucose levels are high or low. Therefore, this intervention should be included in the care plan.

Choice D rationale:

Administering an extra dose of insulin if the client’s blood glucose level drops to 50 mg/dl is not recommended. If a person’s blood glucose level is already low, administering additional insulin can lead to an insulin overdose, which can be lifethreatening. Therefore, this intervention should not be included in the care plan.

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale:

A WBC count of 16,000/mm is higher than the normal range of 5,000 to 10,000 cells/mm. This indicates that the body is fighting an infection, which is a common reason for prescribing Vancomycin. Therefore, a high WBC count could indicate a therapeutic response to the medication as it suggests that the body’s immune system is actively fighting the infection.

Choice B rationale:

A BUN level of 42 mg/dl is higher than the normal range of 7 to 20 mg/dL3456. Elevated BUN levels can indicate kidney damage or disease, which is not a desired therapeutic response to Vancomycin. Vancomycin can be nephrotoxic, and its use requires careful monitoring of kidney function. Therefore, a high BUN level does not indicate a therapeutic response to the medication. Choice C rationale:

A blood pressure reading of 95/64 is considered normal. Maintaining normal blood pressure is important for overall health and can indicate that the patient’s body is responding well to the medication. Therefore, a blood pressure reading within the normal range could indicate a therapeutic response to Vancomycin.

Choice D rationale:

A body temperature of 101.8F is considered a fever14. Fever is a common response to infection and can indicate that the body is fighting off an infection, which is a common reason for prescribing Vancomycin. Therefore, a high body temperature could indicate a therapeutic response to the medication as it suggests that the body’s immune system is actively fighting the infection.

A. Stop taking this drug as soon as your symptoms subside. B. Avoid tanning beds while on this medication. C. Take this medication with 8oz of juice. D. Restrict your daily fluid intake to 1000ml per day.

Correct Answer is ["B","C"]

Explanation

Choice A rationale:

This statement is incorrect. Sulfonamides should be taken for the full time of treatment, even if the patient begins to feel better after a few days. If the medication is stopped too soon, the symptoms may return.

Choice B rationale:

This statement is correct. Sulfonamides can cause increased photosensitivity, which means the skin can be more sensitive to the sun and burn more easily. Therefore, patients should be educated to use sunscreen and protective clothing with sun exposure.

Choice C rationale:

This statement is correct. Sulfonamides are best taken with a full glass (8 ounces) of water. Several additional glasses of water should be taken every day, unless otherwise directed by the doctor. Drinking extra water will help to prevent some unwanted effects of sulfonamides.

Choice D rationale:

This statement is incorrect. Restricting daily fluid intake to 1000ml per day while on sulfonamides could increase the risk of crystalluria that can cause kidney stones or decreased kidney function. Therefore, patients should increase their water intake while taking these medications.

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A nurse is contributing to the care plan for a client who has recently been diagnosed with type 2 diabetes mellitus. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Examine the following patient data for a patient who has been prescribed vancomycin. The nurse is evaluating a patient after administering several doses of Vancomycin IV. Which of the following changes would indicate a therapeutic response to the medication? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is ["B","C"]

Explanation

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