A client with type 1 diabetes mellitus calls the home care nurse and reports taking a morning dose of 70/30 insulin before realizing they have a stomach virus and are now unable to eat breakfast due to nausea. Which initial instruction should the nurse provide the client?
Drink regular colas frequently throughout the day until the nausea subsides.
Do not inject any additional insulin until solid food can be tolerated.
Go to the emergency room as soon as possible for glucose administration.
Continue to monitor blood glucose levels and drink fluids as tolerated.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Stool with fatty streaks is not a common finding in ulcerative colitis. It is more associated with malabsorption syndromes.
Choice B reason: Blood in the stool is a significant finding in ulcerative colitis, especially during an acute exacerbation. It indicates active inflammation and potential bleeding in the colon, which requires immediate attention and intervention.
Choice C reason: Clay-coloured stool usually indicates a problem with the bile ducts or liver, such as bile duct obstruction. It is not specific to ulcerative colitis.
Choice D reason: Hard pellets of stool indicate constipation, which is not typically associated with ulcerative colitis, especially during an acute exacerbation where diarrhea is more common.
Correct Answer is C
Explanation
Choice A reason: Notifying the charge nurse that the client will need assignment to the COVID-19 specified area of the facility is an important action for infection control. However, the most immediate priority is to protect oneself and others by maintaining appropriate distance and using PPE.
Choice B reason: Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is necessary for safe specimen handling and to prevent contamination. While important, it follows after ensuring that proper PPE is used and distancing measures are maintained.
Choice C reason: Maintaining a 6 feet (1.8 meters) distance from the client unless wearing an N95 respirator and personal protective equipment (PPE) for droplet precautions is the most crucial action. This step ensures the nurse’s safety and reduces the risk of virus transmission. Proper PPE and distancing protocols are essential in managing a suspected COVID-19 case.
Choice D reason: Starting an intravenous infusion for an antiviral drug to be administered for positive COVID-19 test results is part of the treatment plan if the test comes back positive. However, this step comes after ensuring safety through proper use of PPE and maintaining distance from the client.
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