The nurse administers regular insulin SUBQ at 0700 to a client with type 1 diabetes mellitus (DM), after which the client eats one-half of the breakfast provided. At 1000, the client reports being hungry. Which action should the nurse implement?

Administer insulin per sliding scale.

Start hourly blood glucose monitoring.

Initiate an IV bolus of 0.9% sodium chloride.

Provide a snack of cheese and crackers.

Answer and Explanation

The Correct Answer is D

Choice A reason: Administering insulin per sliding scale is typically based on blood glucose levels, not just the client's report of hunger. Since the client has already received insulin, providing more insulin without knowing the current blood glucose level could cause hypoglycaemia.

Choice B reason: Starting hourly blood glucose monitoring might be necessary in certain situations, but the immediate need is to address the client's hunger, which could be a sign of impending hypoglycaemia. Addressing the hunger first is more urgent.

Choice C reason: Initiating an IV bolus of 0.9% sodium chloride is not indicated in this scenario. This intervention is typically used for dehydration or other fluid imbalances, not for managing hunger or blood glucose levels directly.

Choice D reason: Providing a snack of cheese and crackers is the most appropriate action. The client's report of hunger after receiving insulin and eating only half of breakfast suggests they might be at risk for hypoglycaemia. A snack will help stabilize their blood glucose levels and prevent hypoglycaemia.

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Correct Answer is B

Explanation

Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.

Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.

Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.

Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.

A. Review the client's fluid intake prior to bedtime. B. Obtain a fingerstick blood glucose level. C. Collect a urine specimen for culture analysis. D. Palpate the bladder above the symphysis pubis.

Correct Answer is D

Explanation

Choice A reason: Reviewing the client's fluid intake prior to bedtime is important for managing nocturia, but it does not address the immediate concern of urinary retention and difficulty starting the urinary stream.

Choice B reason: Obtaining a fingerstick blood glucose level is relevant for diagnosing diabetes, which can cause increased urination. However, it does not directly address the current urinary symptoms.

Choice C reason: Collecting a urine specimen for culture analysis can help identify a urinary tract infection, but it does not provide immediate assessment information regarding the client's bladder status.

Choice D reason: Palpating the bladder above the symphysis pubis is the most immediate and relevant intervention. This assessment helps determine if the bladder is distended, indicating urinary retention, which is a common issue in older adult males and can cause the symptoms described.

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The nurse administers regular insulin SUBQ at 0700 to a client with type 1 diabetes mellitus (DM), after which the client eats one-half of the breakfast provided. At 1000, the client reports being hungry. Which action should the nurse implement?

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Correct Answer is B

Explanation

Correct Answer is D

Explanation

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