A nurse is discussing the care of a client who has type 1 diabetes mellitus with an assistive personnel (AP). Which of the following situations should the nurse instruct the AP to report immediately?

The client refuses breakfast and requests to sleep.

The client asks the AP to trim his broken toenail.

The client reports urine that is dark yellow in color.

The client reports dizziness when standing.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Type 1 diabetes mellitus is a chronic medical condition that occurs when the pancreas, an organ in the abdomen, produces very little or no insulin. Insulin is a hormone that helps the body to use glucose for energy. Glucose is a sugar that comes, in large part, from foods we eat. Insulin allows glucose to enter cells in the body. Therefore, if a client with type 1 diabetes refuses breakfast and requests to sleep, it could lead to hypoglycemia, a condition characterized by abnormally low blood glucose levels. Hypoglycemia can cause symptoms such as weakness, sweating, confusion, and in severe cases, unconsciousness or seizures. It is a medical emergency and should be reported immediately.

Choice B rationale:

Trimming a toenail may seem like a simple task, but for a person with diabetes, it can lead to serious complications. Diabetes can cause nerve damage that leads to numbness in the feet, making it difficult for a person to feel a cut, blister, or sore. These injuries can become infected and lead to serious complications, such as the need for amputation. However, this situation is not as immediately life-threatening as hypoglycemia and does not need to be reported immediately.

Choice C rationale:

Dark yellow urine can be a sign of dehydration, which can be a concern for individuals with diabetes. However, it can also be a result of less serious causes such as certain medications, foods, or simply not drinking enough fluids. While it’s important for the AP to encourage the client to drink more fluids, this situation is not as immediately life-threatening as hypoglycemia.

Choice D rationale:

Dizziness when standing, also known as orthostatic hypotension, can be a side effect of some medications used to treat diabetes. It can also be a symptom of dehydration or other conditions. While it’s important for the AP to monitor the client’s symptoms and report any changes, this situation is not as immediately life-threatening as hypoglycemia

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Correct Answer is D

Explanation

Choice A rationale:

Administering the antibiotic dose before obtaining the cultures could potentially affect the results of the cultures. Antibiotics are designed to kill or inhibit the growth of bacteria, so administering them before obtaining the cultures could lead to false negatives. This could lead to incorrect or delayed diagnosis and treatment.

Choice B rationale:

While obtaining the urine culture before administering the antibiotic dose is a good step, it should not be done before obtaining the blood culture. Blood cultures are usually obtained before urine cultures because they can help identify bacteria or fungi in the blood. This can be crucial in diagnosing conditions like sepsis. Furthermore, administering the antibiotic dose before obtaining the blood culture could affect the results of the culture.

Choice C rationale:

Obtaining the blood culture before administering the antibiotic dose is a good step, but the urine culture should also be obtained before the antibiotic dose is administered. Administering the antibiotic dose before obtaining all necessary cultures could affect the results of the cultures and lead to incorrect or delayed diagnosis and treatment.

Choice D rationale:

This is the correct sequence of actions. The nurse should first obtain both blood and urine cultures before administering the antibiotic dose. This is because the antibiotic could potentially kill or inhibit the growth of bacteria, which could affect the results of the cultures. By obtaining the cultures first, the healthcare team can ensure they are getting accurate results that have not been influenced by the antibiotics. This can lead to a more accurate diagnosis and more effective treatment plan.

A. Double vision B. Tendonitis and tendon rupture C. Neuralgia D. Hypotension

Correct Answer is B

Explanation

Choice A rationale:

Double vision is not a common side effect of quinolones. Quinolones are a type of antibiotic that are used to kill or inhibit the growth of bacteria. While they can have side effects, double vision is not typically one of them.

Choice B rationale:

Tendonitis and tendon rupture are known adverse effects of quinolones. These antibiotics can very rarely cause long-lasting, disabling, and potentially irreversible side effects, sometimes affecting multiple systems, organ classes, and senses. One of these side effects is damage to the tendons, which can manifest as tendonitis (inflammation of the tendon) or even tendon rupture. This is particularly a concern for people older than 60 years and for those with renal impairment or solid-organ transplants because they are at a higher risk of tendon injury.

Choice C rationale:

Neuralgia, or nerve pain, is not a common side effect of quinolones. While these antibiotics can affect the nervous system and cause side effects such as peripheral neuropathy and central nervous system effects, neuralgia is not typically reported.

Choice D rationale:

Hypotension, or low blood pressure, is not typically associated with the use of quinolones. These antibiotics can have various side effects, but a significant drop in blood pressure is not commonly reported.

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A nurse is discussing the care of a client who has type 1 diabetes mellitus with an assistive personnel (AP). Which of the following situations should the nurse instruct the AP to report immediately?

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Correct Answer is D

Explanation

A 79-year-old patient is receiving a quinolone for treatment of a complicated incision infection. For which adverse effect associated with these drugs should the nurse monitor?

Correct Answer is B

Explanation

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