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
Explanation
Choice A rationale:
Hypoglycemia, also known as low blood sugar, is a condition where blood sugar levels fall below the standard range. It is often related to diabetes treatment. When blood glucose levels are too low, individuals may experience symptoms such as shakiness, which is why the statement “I will feel shaky” indicates an understanding of the manifestations of hypoglycemia.
Choice B rationale:
The statement “My skin will be warm and moist” does not accurately represent the symptoms of hypoglycemia. While sweating can be a symptom of hypoglycemia, it does not necessarily mean that the skin will feel warm and moist. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.
Choice C rationale:
The statement “I will be more thirsty than usual” is more commonly associated with hyperglycemia, or high blood sugar, rather than hypoglycemia. Thirst is not typically a symptom of low blood sugar. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.
Choice D rationale:
The statement “My appetite will be decreased” is not a typical symptom of hypoglycemia. In fact, hunger is a common symptom of low blood sugar. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.
Correct Answer is ["50 "]
Explanation
The question is about calculating the volume of phenytoin oral solution that the nurse should administer per dose. The client is prescribed 250 mg of phenytoin and the available solution has a concentration of 25 mg/5 mL.
Let’s calculate the volume step by step:
Step 1: Identify the prescribed dose and the concentration of the available medication. The prescribed dose is 250 mg and the concentration of the available medication is 25 mg/5 mL.
Step 2: Set up the calculation. We want to find out how many mL correspond to the prescribed dose. We can set up the calculation as follows: (Prescribed dose ÷ Concentration) × Volume.
Step 3: Substitute the known values into the calculation. This gives us: (250 mg ÷ 25 mg/5 mL).
Step 4: Perform the division operation first due to the order of operations (BIDMAS/BODMAS). This gives us: (250 mg ÷ 5 mg/mL).
Step 5: Perform the final calculation. This gives us: 50 mL.
So, the nurse should administer 50 mL of the phenytoin oral solution per dose.
Please note that this calculation assumes that the prescribed dose (250 mg) is to be administered in one go. If the dose is to be split over the day, the volume to be administered would change accordingly.
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