An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair.
The patient reports feeling very weak and jittery.
What actions should the nurse take? (Select all that apply)
Check fingerstick glucose level.
Assess skin temperature and moisture.
Administer a PRN dose of regular insulin.
Document anxiety on the surgical checklist.
Measure pulse and blood pressure.
Correct Answer : A,B,E
Choice A rationale
Checking the fingerstick glucose level is an immediate action that the nurse should take when a patient with type 2 diabetes reports feeling weak and jittery. These symptoms could indicate hypoglycemia, a condition characterized by low blood sugar levels.
Choice B rationale
Assessing skin temperature and moisture can help the nurse determine if the patient is sweating, a common symptom of hypoglycemia.
Choice C rationale
Administering a PRN dose of regular insulin is not the appropriate action if the patient is experiencing symptoms of hypoglycemia. Insulin would further lower the patient’s blood sugar levels, potentially worsening their condition.
Choice D rationale
Documenting anxiety on the surgical checklist may not be immediately helpful in addressing the patient’s current symptoms. While it’s important to document all relevant information, the nurse’s immediate focus should be on assessing and managing the patient’s symptoms.
Choice E rationale
Measuring pulse and blood pressure can provide important information about the patient’s cardiovascular status. Hypoglycemia can cause tachycardia and potentially hypotension, so these vital signs should be monitored.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While the activity level of bowel sounds can provide information about the functioning of the gastrointestinal system, it is not the most important data to manage the patient’s pain from chronic pancreatitis.
Choice B rationale
The level and amount of physical activity can affect the patient’s pain level, but it is not the most crucial data for managing pain in chronic pancreatitis.
Choice C rationale
Eating patterns of dietary intake are the most important data to manage the patient’s pain. In chronic pancreatitis, certain foods can exacerbate the pain. Understanding the patient’s dietary habits can help in providing appropriate dietary modifications.
Choice D rationale
The color and consistency of feces can provide information about the patient’s digestive health, but it is not the most important data to manage the patient’s pain from chronic pancreatitis.
Correct Answer is A
Explanation
Choice A rationale
The client’s presentation of chest pain radiating to the left arm, shortness of breath, and diaphoresis are classic symptoms of a myocardial infarction (heart attack)56. Morphine is often administered in this situation to relieve pain and reduce the workload of the heart.
Choice B rationale
Oxycodone is a strong opioid medication used to treat severe pain. However, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
Choice C rationale
Hydromorphone is another strong opioid medication used to treat severe pain. Like oxycodone, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
Choice D rationale
Fentanyl is a potent opioid pain reliever. While it can be used in the management of severe pain, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today