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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A numeric pain scale quantifies pain intensity but not its quality, such as burning or stabbing. Descriptive data provide a fuller picture of pain characteristics, which guide treatment. Numbers alone lack the detail needed to assess the nature of the pain experience.
Choice B reason: Observing body language and movement, like grimacing or guarding, indicates pain presence but not its specific quality. Subjective descriptions from the client reveal characteristics like sharpness or throbbing, which are critical for diagnosis and management, making observation secondary to verbal reports.
Choice C reason: Asking the client to describe the pain captures its quality, including type, location, and pattern (e.g., burning, stabbing). This subjective data is essential for diagnosing the pain’s cause and tailoring treatment, as it provides detailed insights beyond intensity or observable signs, making it the best approach.
Choice D reason: Identifying effective pain relief measures is part of pain management, not assessment of pain quality. Understanding the pain’s characteristics through description is necessary before selecting interventions. This approach is premature without first gathering detailed subjective data from the client.
Correct Answer is A
Explanation
Choice A reason: Monitoring daily urine output assesses kidney function and fluid balance, as urine volume reflects hydration and electrolyte homeostasis. Inadequate output signals dehydration or renal issues, allowing timely intervention to maintain fluid and electrolyte balance, making it the most effective nursing action.
Choice B reason: Salt tablets after exercise replace sodium lost in sweat but are not a universal intervention for fluid and electrolyte balance. They risk hypernatremia if overused. Monitoring urine output is more comprehensive, as it directly evaluates fluid status across various clinical scenarios.
Choice C reason: Reviewing food labels for sodium content helps manage dietary intake but is indirect and patient-dependent. Urine output monitoring provides objective data on fluid and electrolyte status, enabling timely adjustments in therapy, making it a more immediate and reliable intervention.
Choice D reason: Drinking water when thirsty supports hydration but relies on subjective thirst, which may be impaired in certain conditions. Monitoring urine output objectively assesses fluid balance, detecting imbalances early, making it a more proactive and precise intervention than thirst-driven hydration.
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