An overweight, young adult client who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The client reports feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)
Measure pulse and blood pressure
Document anxiety on the surgical checklist
Assess skin temperature and moisture
Check fingerstick glucose level
Administer a PRN dose of regular insulin
Correct Answer : A,C,D,E
A. Measure pulse and blood pressure:
This action is crucial to assess the client's cardiovascular status. Weakness and jitteriness can be related to changes in blood pressure or cardiac function. Measuring pulse and blood pressure helps determine the client's hemodynamic stability.
B. Document anxiety on the surgical checklist:
While anxiety is a valid consideration, addressing the physiological aspects of the client's symptoms takes precedence.
C. Assess skin temperature and moisture:
Assessing skin temperature and moisture provides information about the client's perfusion and hydration status. Changes in skin characteristics can be indicative of underlying issues, and in a diabetic patient, it's important to monitor for potential complications affecting skin integrity.
D. Check fingerstick glucose level:
Given the client's recent diagnosis of type 2 diabetes mellitus and the reported symptoms of weakness and jitteriness, checking the fingerstick glucose level is crucial. Fluctuations in blood glucose levels, whether hyperglycemia or hypoglycemia, can contribute to these symptoms. This test provides immediate information about the client's glycemic status.
E. Administer a PRN dose of regular insulin:
If the fingerstick glucose level indicates hyperglycemia and the healthcare provider has prescribed a PRN (as needed) dose of regular insulin for high blood sugar, administering insulin may be necessary to address hyperglycemia promptly. This is in line with diabetes management protocols, and the nurse should follow specific orders and guidelines for insulin administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Measure the client's blood pressure:
While monitoring blood pressure is an important aspect of assessing a client's overall condition, it is not the immediate priority in a suspected opioid overdose. Respiratory depression and difficulty in arousing are more critical concerns that warrant prompt intervention with naloxone.
B. Remove all of the morphine patches:
While eventually, the nurse will need to address the presence of multiple morphine patches, removing them is not the first action. Administering naloxone to reverse the opioid effects takes precedence over patch removal.
C. Apply oxygen per face mask:
While providing oxygen may be necessary to support respiratory function, it doesn't address the underlying cause of the respiratory distress, which is likely opioid toxicity. Administering naloxone is the more direct and immediate intervention to counteract the effects of the opioids.
D. Administer a narcotic antagonist:
This is the correct and immediate priority. If the client is difficult to arouse and has multiple morphine patches, it raises concerns about opioid toxicity. Naloxone is a narcotic antagonist that can reverse the effects of opioid overdose, particularly respiratory depression, and is crucial in this scenario to restore normal respiratory function.
Correct Answer is C
Explanation
A. Begin continuous observation for transient episodes of neurologic dysfunction:
While continuous observation is important, the priority is to notify the stroke team for immediate assessment and management.
B. Place an indwelling urinary catheter and measure strict intake and output:
Monitoring intake and output is an important aspect of nursing care, but it is not the immediate priority when the client is presenting with signs and symptoms suggestive of a stroke.
C. Notify the stroke team to assist with acute assessment and management.
The client's symptoms, including an uneven smile with facial droop to the right side, weaker hand grasp strength on the right, and sudden, severe headache, are indicative of potential stroke symptoms. Quick notification of the stroke team is crucial to facilitate a rapid and comprehensive assessment. Time is a critical factor in the management of stroke, and prompt intervention can improve outcomes.
D. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment:
While positioning is important for maintaining physiological stability, it is not the immediate priority in the context of a potential stroke. Notifying the stroke team for rapid assessment and intervention takes precedence.
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