A 46-year-old woman who was diagnosed with an upper respiratory infection yesterday and prescribed an antibiotic presents to the ED reporting. "l just don't feel right." The client has a history of diabetes mellitus type 2, hypertension, peripheral neuropathy, vascular disease, and retinopathy. On admission to a medical-surgical unit, the nurse implements a plan of care to prevent complications and maintain client safety while in the hospital.
Indicate which nursing action is appropriate to prevent complications of diabetes mellitus and maintain client safety while in the hospital.
Administer angiotensin-converting enzyme (ACE) inhibitor as prescribed.
Administer intravenous 5%D/NS at 200 mL/hr.
Administer I mg glucagon 1M PRN for blood glucose 70-90 mg/dL (3.9-5.0 mmol/L).
Ensure the path to the bathroom is well-lit.
Teach the client to rise slowly from the bed.
Coordinate meal-time insulin with food delivery and consumption.
Correct Answer : D,F,G
Option A is incorrect because administering an ACE inhibitor may be a part of the patient's regular medication regimen, but it is not specific to preventing complications of diabetes mellitus while in the hospital.
Option b is incorrect because administering intravenous fluids at a high rate may result in fluid overload, electrolyte imbalances, and other complications, which may not be appropriate for this patient.
Option c is incorrect because administering glucagon is not a preventative measure, but rather an intervention for treating hypoglycemia.
Option d is correct because ensuring a well-lit path to the bathroom is important for fall prevention, but it does not directly address the prevention of complications of diabetes mellitus.
Option e is incorrect because encouraging the client to drink sugar-free liquids is a general recommendation for maintaining hydration and may not be specific to preventing complications of diabetes mellitus.
Option f is correct because teaching the client to rise slowly from the bed is important for preventing orthostatic hypotension, but it does not directly address the prevention of complications of diabetes mellitus.
Option g is correct because Patients with diabetes mellitus are at risk for hypoglycemia when taking insulin or oral hypoglycemic agents. Proper coordination of meal-time insulin with food delivery and consumption can help prevent hypoglycemia or hyperglycemia. This includes ensuring that the patient receives insulin at the appropriate time in relation to meals and monitoring blood glucose levels regularly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Prochlorperazine is an antiemetic medication that is commonly used to treat nausea and vomiting caused by various conditions, including chemotherapy, radiation therapy, and surgery. Giving the medication before the dressing changes, can prevent or minimize the onset of nausea and vomiting, which can be triggered by the pain and anxiety associated with the procedure.
Option B, keeping the patient NPO (nothing by mouth) for 2 hours before dressing changes, may be helpful in reducing the risk of aspiration if the patient needs sedation or general anesthesia for the procedure. However, it is not directly related to reducing the patient's nausea.
Option C, avoiding performing dressing changes close to the patient's mealtimes, may help reduce the risk of nausea caused by an overly full stomach, but it is not directly related to reducing the patient's nausea during the procedure.
Option D, administering prescribed morphine sulfate before dressing changes, may help reduce the patient's pain during the procedure, but it may also increase the risk of nausea and vomiting as a side effect. Therefore, this option may not be the most useful in decreasing the patient's nausea.
Correct Answer is A
Explanation
The most helpful finding by the nurse in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (pyelonephritis) would be
**costovertebral tenderness**⁴. This is because costovertebral tenderness is a common symptom of pyelonephritis⁵. Pyelonephritis is an infection of the upper urinary tract that can cause fever, chills, flank pain, nausea, vomiting, and costovertebral tenderness⁵. Foul-smelling urine and bladder distention are not specific symptoms of pyelonephritis⁵. Suprapubic discomfort can be a symptom of lower urinary tract infection⁵.
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