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 ["A","C","D"]
Explanation
Choice A rationale
Eating a diet that is high in protein and vitamins A and C is beneficial for wound healing. Protein is essential for tissue repair, while vitamins A and C play a crucial role in collagen synthesis, which is vital for wound healing.
Choice B rationale
Maintaining bed rest as much as possible is not the best advice for a patient with venous leg ulcers. Mobility improves blood circulation, which can aid in the healing of the ulcers.
Choice C rationale
Keeping legs elevated when sitting or lying down can help reduce swelling and improve blood flow, which can promote healing of the ulcers.
Choice D rationale
Inspecting ankles daily for areas of darkening skin is important as it can help in early detection of any potential complications or worsening of the condition.
Choice E rationale
Applying intermittent cold compresses four times daily is not typically recommended for venous leg ulcers. The standard treatment involves cleaning and dressing the wound, using compression therapy, and in some cases, taking prescribed medications.
Correct Answer is B
Explanation
Choice A rationale
While monitoring skin for breakdown is an important aspect of nursing care, especially for bedridden or immobile patients, it is not the most important intervention for a client admitted with possible anastomosis leakage.
Choice B rationale
An anastomotic leak is a serious complication that occurs when the surgical connection between two parts of the intestine leaks, allowing the contents of the gastrointestinal tract to leak into the abdominal cavity. This can lead to serious infection and sepsis. Strict intravenous
(IV) fluid replacement is crucial in this situation to prevent dehydration and maintain blood pressure.
Choice C rationale
Encouraging regular turning is an important aspect of nursing care to prevent pressure ulcers, especially for bedridden or immobile patients. However, it is not the most important intervention for a client admitted with possible anastomosis leakage.
Choice D rationale
Assessing wound drainage daily is an important aspect of postoperative care. However, in the case of a suspected anastomotic leak, more immediate and critical interventions are required.
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