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. Instruct the client to avoid foods with gluten, such as wheat bread.
While some individuals with Crohn's disease may experience improvement by avoiding certain types of carbohydrates, including gluten, this recommendation is not universally applicable to all individuals with Crohn's disease. Gluten restriction is more relevant for those with gluten sensitivity or celiac disease.
B. Explain that the need to restrict fluids is the primary limitation.
This statement is not accurate. Fluid restriction is not a primary dietary limitation for individuals with Crohn's disease. In fact, maintaining adequate hydration is generally important for overall health. Restricting fluids is not a standard dietary recommendation for managing Crohn's disease.
C. Advise the client to limit foods that are high in calcium and iron.
Limiting foods high in calcium and iron is not a standard recommendation for Crohn's disease. In fact, adequate intake of essential nutrients, including calcium and iron, is important for overall health. Limiting these nutrients could lead to nutritional deficiencies.
D. Describe the use of an elimination diet to find trigger foods.
This is the most appropriate response. Crohn's disease symptoms can vary among individuals, and identifying trigger foods through an elimination diet can help personalize dietary recommendations. By systematically eliminating and reintroducing foods, individuals can identify which specific foods may exacerbate their symptoms.
Correct Answer is ["0.4"]
Explanation
Step 1: Use the Formula
mL = units prescribed ÷ units per mL
Step 2: Plug in the Given Values
mL = 200,000 ÷ 500,000
Step 3: Simplify the Fraction
mL = 2 ÷ 5
Step 4: Convert the Fraction to a Decimal
mL = 0.4 mL
The nurse should administer 0.4 mL of penicillin to this client.
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