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 ["B","C","D"]
Explanation
Choice A rationale:
Polyuria, which is frequent or excessive urination, is not typically a symptom of hypoglycemia. It is more commonly associated with hyperglycemia, or high blood sugar levels.
Choice B rationale:
Sweating is indeed a common symptom of hypoglycemia. When blood sugar levels fall too low, the body may respond by sweating as it releases adrenaline in response to the hypoglycemic state.
Choice C rationale:
Tachycardia, or a fast heartbeat, is another common symptom of hypoglycemia. This is part of the body’s response to low blood sugar levels, as it releases adrenaline to try to raise these levels.
Choice D rationale:
Blurry vision can be a symptom of hypoglycemia. When blood sugar levels fall, it can affect the ability of the eyes to focus, leading to blurry vision.
Choice E rationale:
Polydipsia, or excessive thirst, is not typically a symptom of hypoglycemia. Like polyuria, it is more commonly associated with hyperglycemia.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.