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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Drinking regular colas can lead to fluctuations in blood glucose levels and is not an appropriate recommendation for managing nausea in a client with diabetes.
Choice B reason: Not injecting additional insulin until solid food can be tolerated is not advisable, as it may lead to hyperglycaemia or diabetic ketoacidosis. Insulin needs to be managed carefully even if the client is not eating.
Choice C reason: Going to the emergency room immediately may not be necessary if the client can manage their blood glucose levels at home with proper guidance.
Choice D reason: Monitoring blood glucose levels and drinking fluids as tolerated is the best initial advice. This helps prevent dehydration and maintain glucose control while dealing with the nausea. The client should also follow sick day management guidelines for diabetes and stay in touch with their healthcare provider.
Correct Answer is B
Explanation
Choice A reason: Leaving the door open so the client recognizes her belongings might help, but it is not the most effective solution. It relies on the client being able to remember and identify her possessions, which can be challenging with Alzheimer's disease.
Choice B reason: Placing a picture of the client on her door is an effective intervention. It provides a clear visual cue that the client can easily recognize, helping her to identify her own room without relying on memory alone. This approach uses a personal and familiar image, making it easier for the client to find her room.
Choice C reason: Putting a bright red balloon on the client's door may attract attention but does not provide a personal or meaningful cue for the client. While it might help distinguish the door, it lacks the personal connection needed for effective recognition.
Choice D reason: Enlarging the letters of her name on the door can help, but it still relies on the client's ability to read and recognize her name, which may be impaired. A picture of the client is a more straightforward and effective visual aid.
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