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 A
Explanation
A. Family members can help with regular foot exams:
This is the correct answer. Regular foot exams are essential for individuals with diabetes, especially those with peripheral neuropathy. Family members can assist in identifying any changes, cuts, or wounds on the feet that the client might not be able to perceive due to neuropathy.
B. Heating pads are useful if on the lowest setting:
The use of heating pads is generally not recommended for individuals with peripheral neuropathy. They may have reduced sensation, making it difficult to detect if the pad is too hot, leading to the risk of burns.
C. Aching feet may be soaked in lukewarm water for one hour or more:
Prolonged soaking of feet is not advisable, as it can lead to maceration of the skin and increase the risk of infection. A short, lukewarm foot soak is generally acceptable, but the duration should be limited.
D. Shoes should be worn outside the house, but it is fine to be barefoot inside:
Individuals with diabetes and peripheral neuropathy should wear protective footwear both inside and outside the house to prevent injuries and reduce the risk of complications.
Correct Answer is D
Explanation
A. Initiate cardiac telemetry:
Cardiac telemetry is not the immediate priority in this case. Kidney stones are more likely to cause severe localized pain rather than cardiac-related symptoms.
B. Administer a PRN dose of a laxative:
Laxatives are not indicated for the management of kidney stones or the associated flank pain. The priority is to address the specific needs related to the possible passage of kidney stones.
C. Implement seizure precautions:
Seizure precautions are not relevant to the sudden onset of severe flank pain in the context of hyperparathyroidism. The focus should be on managing pain, assessing for kidney stone passage, and addressing the underlying cause.
D. Begin straining all urine.
Straining all urine allows for the collection and examination of any passed stones. This information is important for identifying the composition of the stones and guiding further management.
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