At 8 a.m. the nurse is reviewing patient assignments and notes one of the patients has a current blood glucose of 264. Breakfast is routinely served at 8:30. The following orders are noted in the chart. What action should the nurse take? Accucheck before meals and at bedtime with sliding scale insulin aspart SQ: Glucose 0-150 Administer 0 units; 151-200 Administer 2 units; 201-250 Administer 4 units: 251-300 Administer 6 units: 301-350 Administer 8 units; 351- 400 Administer 10 units; >400 Notify physician.

Provide 2 units insulin aspart 50

Provide 6 units insulin aspart 50

Provide 10 units insin apart SQ

Provide 4 units insulin aspart 50

Answer and Explanation

The Correct Answer is B

A. This option corresponds to the blood glucose range of 151-200. However, the patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 2 units would not be appropriate in this case.

B. The patient's current blood glucose level is 264, which falls into the range of 251-300. According to the sliding scale insulin aspart orders, for this range, 6 units should be administered. This option aligns with the patient's blood glucose level and the prescribed protocol.

C. This option corresponds to the blood glucose range of 351-400. The patient's blood glucose level of 264 does not fall into this range, so administering 10 units would be excessive and potentially lead to hypoglycemia.

D. This option corresponds to the blood glucose range of 201-250. The patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 4 units would not be sufficient to address the elevated blood glucose level.

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Correct Answer is D

Explanation

A. Drowsiness is not a typical manifestation of thyrotoxicosis. Instead, individuals with thyrotoxicosis often experience restlessness and anxiety due to excessive thyroid hormone levels.

B. Dry skin is more commonly associated with hypothyroidism (insufficient thyroid hormone levels), rather than thyrotoxicosis (excessive thyroid hormone levels).

C. Bradycardia (slower than normal heart rate) is a symptom of hypothyroidism, not thyrotoxicosis. In thyrotoxicosis, tachycardia (an abnormally rapid heart rate) is a common finding.

D. Correct. Heat intolerance is a classic symptom of thyrotoxicosis. Excessive thyroid hormone levels can lead to an increased metabolic rate, making individuals more sensitive to heat.

A. "Withhold your usual daily dose of insulin." B. "Drink 240 to 360 milliliters of calorie-free liquids every 8 hours." C. "Test your blood glucose level every 8 hours." D. "Check your urine for ketones when blood glucose levels are greater than 240 mg/dL."

Correct Answer is D

Explanation

A. Incorrect. Withholding insulin during illness is not recommended. Clients with type 1 diabetes should continue to take their prescribed insulin even when they are ill. Insulin is necessary to regulate blood glucose levels, and illness can increase the body's demand for insulin.

B. Incorrect. Drinking calorie-free liquids is important to prevent dehydration during illness, but specific fluid amounts should be individualized based on the client's needs and healthcare provider's recommendations. The given volume is not a universally applicable guideline.

C. Incorrect. Testing blood glucose levels every 8 hours may not be frequent enough during illness. Blood glucose should be monitored more frequently to closely track changes in response to illness and adjust insulin doses accordingly.

D. Correct. Checking urine for ketones when blood glucose levels exceed 240 mg/dL is an important guideline during illness. Elevated blood glucose levels can lead to the production of ketones, and checking for ketones in the urine helps identify the early signs of diabetic ketoacidosis (DKA). If ketones are present, the client should follow a specific plan of action as outlined by their healthcare provider, which may include adjusting insulin doses or seeking medical attention.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has thyrotoxicosis after taking too high of a level of levothyroxine. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?

The nurse is assessing an older patient with type 2 diabetes mellitus. What age-related endocrine change should the nurse expect in this patient?

A nurse is assessing a client who has hypoparathyroidism. Which of the following findings should the nurse expect?

A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?

A client is being discharged after having a thyroidectomy. Which discharge instructions are appropriate for this client? Select all that apply.

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?