A nurse is caring for a 28-year-old male client with type 1 diabetes mellitus in the medical-surgical unit on day 3 of hospitalization. Below are the exhibits to guide your answer:
Select the two findings that require immediate follow-up:
Glucose at 1130
Client report of shakiness
Temperature
Oxygen saturation
Correct Answer : A,B
Choice A rationale: A blood glucose level of 55 mg/dL is critically low, indicating hypoglycemia. Immediate intervention is required to prevent potential complications such as loss of consciousness, seizures, or even death. Hypoglycemia in individuals with type 1 diabetes can be life-threatening and requires prompt treatment with fast-acting carbohydrates to restore normal blood glucose levels.
Choice B rationale: The client's report of shakiness, hunger, cool skin, and diaphoresis are classic symptoms of hypoglycemia. These symptoms correlate with the dangerously low blood glucose level and indicate an urgent need for intervention. Addressing these symptoms quickly can prevent further deterioration of the client's condition.
Choice C rationale: While the slight increase in temperature to 37.8°C (100°F) is noteworthy, it does not necessitate immediate intervention compared to the hypoglycemic event. Monitoring for any signs of infection or other issues is important, but it is not the highest priority in this scenario.
Choice D rationale: An oxygen saturation of 97% on room air is within normal limits and does not require immediate follow-up. There are no signs of respiratory distress or hypoxia that would necessitate urgent intervention in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Intestinal malabsorption syndrome is not typically associated with ulcerative colitis or anemia caused by this condition. Malabsorption is more often related to other gastrointestinal conditions.
Choice B rationale
Intestinal parasites are not a common cause of anemia in individuals with ulcerative colitis. The chronic inflammation and blood loss are more likely contributors.
Choice C rationale
Chronic blood loss from the intestinal lining due to ulcerative colitis is a major contributing factor to anemia. The ongoing inflammation and ulceration can cause significant blood loss over time.
Choice D rationale
Dietary iron restrictions are not typically associated with ulcerative colitis. Anemia in this context is more likely due to chronic blood loss rather than dietary deficiencies.
Correct Answer is A
Explanation
Choice A rationale
Monitoring blood glucose levels more frequently is critical when a client with type 1 diabetes is taking prednisone, as corticosteroids can raise blood glucose levels and potentially cause hyperglycemia.
Choice B rationale
Increasing sodium intake is not recommended for clients with type 1 diabetes and is unrelated to the management of prednisone-induced hyperglycemia.
Choice C rationale
Stopping all other diabetes medications is inappropriate and can lead to uncontrolled blood glucose levels. Adjustments may be needed, but discontinuation is not advised without medical supervision.
Choice D rationale
Skipping meals to prevent hyperglycemia is not a safe practice for clients with type 1 diabetes. Maintaining a balanced diet and monitoring blood glucose levels is essential.
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