A newly diagnosed diabetic client is 24 hours post-op following abdominal surgery.
The 0700 blood glucose level is 200 mg/dl and the nurse administers 4 units of insulin aspart subcutaneously per the prescribed sliding scale.

When should the nurse first assess the client for signs and symptoms of hypoglycemia?

0800

0730

1130

1000

Answer and Explanation

The Correct Answer is B

Choice A rationale

Hypoglycemia, or low blood sugar, can occur after insulin administration. However, the onset of hypoglycemia is not immediate. Insulin aspart, a rapid-acting insulin, has a peak action time of approximately 1-3 hours after administration. Therefore, assessing the patient for signs and symptoms of hypoglycemia at 0800, one hour after administration, may be too early.

Choice B rationale

Assessing the patient for signs and symptoms of hypoglycemia at 0730, 30 minutes after insulin administration, is too early. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.

Choice C rationale

Assessing the patient for signs and symptoms of hypoglycemia at 1130, four and a half hours after insulin administration, may be too late. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.

Choice D rationale

Assessing the patient for signs and symptoms of hypoglycemia at 1000, three hours after insulin administration, is within the peak action time of insulin aspart. Therefore, this is the most appropriate time to start assessing the patient for signs and symptoms of hypoglycemia.

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Correct Answer is A

Explanation

Choice A rationale

Acarbose and repaglinide are medications used to manage blood glucose levels in people with type 2 diabetes. Acarbose slows the digestion of carbohydrates in the gut, which helps to prevent spikes in blood glucose after meals. Repaglinide stimulates the pancreas to release more insulin. Both of these medications can cause hypoglycemia, or low blood sugar.

Therefore, carrying glucose tablets or gels is a good practice because they can quickly raise blood sugar levels during an episode of hypoglycemia.

Choice B rationale

Taking these medications on an empty stomach is not recommended. Acarbose should be taken with the first bite of each main meal. Repaglinide should be taken within 30 minutes before meals. Therefore, this statement does not indicate effective teaching.

Choice C rationale

Drinking orange soda to treat symptoms of hypoglycemia is not the best choice. While orange soda can increase blood sugar levels, it also contains other ingredients, like caffeine, that are not beneficial for people with diabetes. Glucose tablets or gels are a better option because they provide a fast-acting source of glucose and are easy to dose.

Choice D rationale

This statement is incorrect. While repaglinide does stimulate the pancreas to release more insulin, it does not mean that the person has to start taking insulin shots. Acarbose works by slowing the digestion of carbohydrates in the gut, not by affecting insulin release. Therefore, this statement does not indicate effective teaching.

A. Complaints of muscle cramps with exercise B. Pedal pulses are +1 bilaterally C. Complaints of burning pain during the night D. Tissue that is blackened on the great toe

Correct Answer is C

Explanation

Choice A rationale

Complaints of muscle cramps with exercise. While muscle cramps with exercise can be a symptom of peripheral arterial disease (PAD), they are more commonly associated with the earlier stages of the disease, known as intermittent claudication.

Choice B rationale

Pedal pulses are +1 bilaterally. Reduced or absent pedal pulses can be a sign of PAD, but a finding of +1 pedal pulses does not necessarily correlate with stage III of the disease.

Choice C rationale

Complaints of burning pain during the night. Stage III PAD, also known as critical limb ischemia, is characterized by more severe symptoms, including discomfort or pain in the feet or toes, even while at rest. Symptoms tend to worsen at night.

Choice D rationale

Tissue that is blackened on the great toe. This is a sign of gangrene, which is a severe and potentially life-threatening complication of PAD2. However, it is not a typical finding in stage III PAD, and would more likely be seen in the most advanced stage of the disease.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a client who has been newly prescribed acarbose in addition to repaglinide for the treatment of Type 2 diabetes. Which statement made by the client indicates that the teaching has been effective?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The client’s chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A client diagnosed with peripheral arterial disease has the nursing problem of Impaired Tissue Integrity related to ischemic tissue of the legs and feet. What is an expected outcome to include in the care plan?

The nurse explains to a patient diagnosed with diabetes mellitus that the major benefit of frequent self-monitoring of blood glucose is that:

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The nurse is aware that a client taking an antibiotic that causes diarrhea should be taught about:

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The nurse is caring for a client who has just returned to the nursing unit following a below-the-knee amputation (BKA) of the right leg. How should this client be positioned?

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