A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?
"Withhold your usual daily dose of insulin."
"Drink 240 to 360 milliliters of calorie-free liquids every 8 hours."
"Test your blood glucose level every 8 hours."
"Check your urine for ketones when blood glucose levels are greater than 240 mg/dL."
The Correct Answer is D
A. Incorrect. Withholding insulin during illness is not recommended. Clients with type 1 diabetes should continue to take their prescribed insulin even when they are ill. Insulin is necessary to regulate blood glucose levels, and illness can increase the body's demand for insulin.
B. Incorrect. Drinking calorie-free liquids is important to prevent dehydration during illness, but specific fluid amounts should be individualized based on the client's needs and healthcare provider's recommendations. The given volume is not a universally applicable guideline.
C. Incorrect. Testing blood glucose levels every 8 hours may not be frequent enough during illness. Blood glucose should be monitored more frequently to closely track changes in response to illness and adjust insulin doses accordingly.
D. Correct. Checking urine for ketones when blood glucose levels exceed 240 mg/dL is an important guideline during illness. Elevated blood glucose levels can lead to the production of ketones, and checking for ketones in the urine helps identify the early signs of diabetic ketoacidosis (DKA). If ketones are present, the client should follow a specific plan of action as outlined by their healthcare provider, which may include adjusting insulin doses or seeking medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- Choice A Rationale: Placing the head of the bed in the flat position is not recommended as it can increase the risk of airway obstruction and reduce venous drainage from the head, which is especially critical after thyroid surgery.
- Choice B Rationale: While deep breathing is important postoperatively, it is not specific to thyroidectomy care and should be done more frequently than every 4 hours to ensure adequate ventilation and prevent atelectasis.
- Choice C Rationale: Hyperextending the client's neck can be harmful post-thyroidectomy as it may put stress on the surgical site, potentially leading to dehiscence or damage to the area.
- Choice D Rationale: Checking the client's voice every 2 hours is essential after a thyroidectomy because vocal cord paralysis can be an indicator of recurrent laryngeal nerve damage, which is a potential complication of the surgery. Monitoring the voice allows for early detection and intervention.
Correct Answer is A
Explanation
A. Serum potassium 2.5 mEq/L and blood pressure 150/90 mmHg - This combination of severe hypokalemia (low potassium) and elevated blood pressure is a concerning finding. It can lead to serious cardiac complications and requires immediate attention.
B. Serum phosphorus 3 mg/dL and hirsutism - While low serum phosphorus may be seen in Cushing syndrome, it is not an immediate concern. Hirsutism (excessive hair growth) is a characteristic feature of Cushing syndrome.
C. Serum calcium 10 mg/dL, and reports of feelings of depression - Although an elevated serum calcium level is not typical in Cushing syndrome, it is not an immediate concern. Reports of depression should be addressed but do not require immediate follow-up.
D. Serum sodium 145 mEq/L and reports of muscle weakness - These findings are not indicative of immediate danger. Elevated serum sodium and muscle weakness can occur in Cushing syndrome, but they do not warrant immediate attention compared to the potassium level and blood pressure in option A.
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