A client with diabetes mellitus is admitted with an acute hyperglycemic episode. Which intervention should the nurse implement?

Fewer fingerstick glucose checks

Higher doses of insulin

Restriction of caloric intake

Increased oral fluid intake

Answer and Explanation

The Correct Answer is B

Choice A reason: Fewer fingerstick glucose checks are dangerous in acute hyperglycemia, as frequent monitoring tracks blood sugar trends, guiding insulin dosing. Reducing checks risks missing critical changes, worsening ketoacidosis or hyperosmolar state, making this intervention counterproductive for managing a diabetic emergency.

Choice B reason: Higher insulin doses are critical, as acute hyperglycemia in diabetes mellitus results from insulin deficiency, causing elevated blood glucose. Insulin lowers glucose by facilitating cellular uptake, preventing ketoacidosis or hyperosmolar coma, making this the priority intervention for rapid glycemic control.

Choice C reason: Restricting caloric intake addresses long-term diabetes management but not acute hyperglycemia, which requires insulin to lower blood glucose. Caloric restriction is secondary, as immediate glycemic control prevents complications, making this intervention less urgent during an acute episode.

Choice D reason: Increased oral fluid intake prevents dehydration but does not correct hyperglycemia. Insulin directly lowers blood glucose, addressing the primary issue, and fluids are supportive, making this intervention secondary to insulin administration for managing an acute hyperglycemic crisis.

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Correct Answer is B

Explanation

Choice A reason: Teaching a family member to administer eye drops is important for post-discharge care but not immediate. Eye protection prevents injury post-surgery, and drops are nurse-administered in-hospital, making this intervention secondary to ensuring the surgical site’s safety.

Choice B reason: Providing an eye shield for sleeping is critical immediately, as the right eye is vulnerable to trauma post-glass removal. The shield prevents accidental rubbing or pressure, reducing infection or displacement risk, making it the priority intervention for postoperative protection.

Choice C reason: Deep breathing and coughing exercises prevent pulmonary issues in major surgeries, not minor eye procedures. These may increase intraocular pressure, risking surgical complications, making this intervention inappropriate and potentially harmful for eye surgery recovery.

Choice D reason: Obtaining vital signs every 2 hours monitors systemic stability but is not specific to eye surgery. Eye shield use prevents immediate trauma, and vital signs are secondary, as local protection is the priority post-glass removal to ensure healing.

A. Apply the client’s home oxygen B. Take client to emergency department (ED) C. Ensure that the client avoids salt intake for the rest of the day D. Check for a thrill and bruit at the client’s dialysis access site

Correct Answer is B

Explanation

Choice A reason: Applying home oxygen addresses hypoxia but not lethargy and unresponsiveness, which suggest uremic encephalopathy or electrolyte imbalance from missed dialysis. Emergency evaluation is critical, as oxygen does not correct metabolic toxins, making this instruction less urgent than ED transfer.

Choice B reason: Taking the client to the ED is critical, as lethargy and unresponsiveness post-missed dialysis indicate uremia or hyperkalemia, life-threatening CKD complications. Immediate dialysis or medical intervention corrects metabolic imbalances, preventing coma or arrhythmias, making this the most important instruction.

Choice C reason: Avoiding salt intake prevents fluid retention but does not address acute lethargy and unresponsiveness, signs of uremic toxicity. Emergency treatment is needed to correct metabolic derangements, and dietary changes are secondary, making this instruction irrelevant for the immediate crisis.

Choice D reason: Checking thrill and bruit assesses dialysis access patency but does not address lethargy and unresponsiveness, indicating systemic toxicity. ED evaluation and dialysis are urgent, as access function is secondary to treating life-threatening uremia, making this instruction less critical.

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A client with diabetes mellitus is admitted with an acute hyperglycemic episode. Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

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Explanation

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