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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
Shortness of breath is a common symptom of a hypersensitivity reaction. This occurs because the body’s immune system responds to a foreign substance, known as an antigen, by producing specific antibodies. This immune response can cause inflammation and swelling in various parts of the body, including the airways, leading to shortness of breath.
Choice B rationale:
A black hairy tongue is not typically associated with a hypersensitivity reaction. It is a condition that causes the tongue to appear black and hairy, and it’s usually caused by an overgrowth of bacteria or yeast on the tongue. It’s not related to allergies or hypersensitivity reactions.
Choice C rationale:
Itching is another common symptom of a hypersensitivity reaction. When the body encounters an antigen, it triggers an immune response that releases chemicals like histamine. Histamine can cause itching, among other symptoms.
Choice D rationale:
Swelling of the tongue can be a symptom of a severe hypersensitivity reaction known as anaphylaxis. This is a medical emergency that requires immediate attention. The swelling is caused by inflammation in response to an antigen.
Choice E rationale:
Wheezing is a symptom of a hypersensitivity reaction, specifically type I hypersensitivity. This type of reaction includes allergic disorders, which affect the lungs among other parts of the body. The immune response to an antigen can cause the airways to narrow and produce a wheezing sound.
Correct Answer is A
Explanation
Choice A rationale:
Zidovudine, also known as AZT, is a medication used for the treatment of human immunodeficiency virus (HIV) infection. One of the major dose-limiting toxic effects of Zidovudine is hematologic toxicity, which manifests clinically as anemia, neutropenia, and sometimes as platelet deficits with onset after several weeks of treatment. This hematologic toxicity is essentially a form of bone marrow suppression. Therefore, bone marrow suppression is the dose-limiting adverse effect of zidovudine therapy.
Choice B rationale:
Retinitis is not a known dose-limiting adverse effect of zidovudine. While zidovudine has a range of side effects, retinitis is not commonly associated with its use.
Choice C rationale:
Renal toxicity is not a known dose-limiting adverse effect of zidovudine. While zidovudine can have various side effects, renal toxicity is not typically one of them.
Choice D rationale:
Hepatotoxicity is not the dose-limiting adverse effect of zidovudine. While severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of zidovudine, it is not considered the dose-limiting adverse effect. The dose-limiting adverse effect is more specifically related to hematologic toxicity, which includes bone marrow suppression.
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