The nurse is caring for a client with type 2 diabetes mellitus who reports frequent episodes of hypoglycemia. Which action should the nurse prioritize?

Increase carbohydrate intake at meals

Review the client’s medication regimen

Monitor blood glucose every hour

Encourage high-protein snacks

Answer and Explanation

The Correct Answer is B

Choice A reason: Increasing carbohydrate intake may prevent hypoglycemia but does not address the root cause, such as excessive insulin or oral hypoglycemic agents. Reviewing medications identifies dosing issues, ensuring safer management of type 2 diabetes, making it the priority over dietary changes.

Choice B reason: Reviewing the medication regimen is critical, as hypoglycemia in type 2 diabetes often results from excessive insulin or sulfonylureas. Adjusting doses or timing with a provider prevents recurrent episodes, addressing the primary cause and ensuring safe glycemic control, making it the priority action.

Choice C reason: Monitoring blood glucose hourly is reactive and impractical long-term. It confirms hypoglycemia but does not prevent it. Reviewing medications addresses the cause, such as inappropriate dosing, making it more effective for managing recurrent hypoglycemia in type 2 diabetes.

Choice D reason: High-protein snacks stabilize blood glucose but are secondary to addressing medication-related hypoglycemia. Excessive insulin or oral agents are likely causes, so reviewing the regimen is prioritized to correct dosing, preventing recurrent episodes more effectively than dietary adjustments alone.

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Correct Answer is A

Explanation

Choice A reason: Rinsing the mouth after using a corticosteroid inhaler prevents oral candidiasis, a common side effect from residual steroid deposition. This ensures safe asthma management, as fungal infections compromise adherence and health, making it the priority teaching point for proper inhaler use.

Choice B reason: Using the inhaler only during asthma attacks applies to rescue inhalers, not maintenance corticosteroids, which are used daily. This is incorrect, as rinsing the mouth is essential for corticosteroid inhalers to prevent oral thrush, ensuring safe and effective asthma control.

Choice C reason: Storing inhalers in a refrigerator is unnecessary and may degrade some medications. Room-temperature storage is standard. Rinsing the mouth after corticosteroid inhaler use is critical to prevent oral candidiasis, making it the priority teaching point for asthma management.

Choice D reason: Shaking the inhaler only once may be insufficient for proper aerosolization in some devices. Rinsing the mouth after corticosteroid inhaler use is the priority, as it prevents oral thrush, a significant side effect, ensuring safe and consistent asthma therapy.

A. Monitor oxygen saturation B. Check skin color C. Assess for chest pain D. Measure blood pressure

Correct Answer is A

Explanation

Choice A reason: Monitoring oxygen saturation is critical in COPD, as oxygen therapy aims to maintain saturation (88–92%) to prevent hypoxia. Pulse oximetry ensures adequate oxygenation, guiding therapy adjustments, making it the priority assessment to prevent respiratory failure and optimize lung function.

Choice B reason: Checking skin color assesses cyanosis but is less precise than oxygen saturation. Pulse oximetry provides objective data on oxygenation in COPD, guiding oxygen therapy, making it the priority over subjective visual assessments, which are secondary to quantitative measures.

Choice C reason: Assessing chest pain is relevant for cardiac issues but not the primary concern in COPD oxygen therapy. Oxygen saturation directly evaluates therapy effectiveness, preventing hypoxia, making it the priority assessment to ensure respiratory stability in chronic lung disease.

Choice D reason: Measuring blood pressure monitors cardiovascular status but is secondary to oxygenation in COPD. Oxygen saturation is critical, as hypoxia exacerbates respiratory distress, requiring immediate assessment to adjust oxygen therapy, making it the priority over hemodynamic evaluations.

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The nurse is caring for a client with type 2 diabetes mellitus who reports frequent episodes of hypoglycemia. Which action should the nurse prioritize?

Nursing Test Bank

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