A nurse is caring for a cent who has diabetes mellitus, type 1 Day 3 of hospital
0700
Temperature 37.3°C (981) Boot
Heart rate 121
118/62 mm Hg Temperature 30.8°
Be pressure 104mm Hg 0730
Fingerstick blood glucose, fasting 110 mg/dl. (74 to 106 mg/dL) NPH insulin 40 units subcutaneous administered into abdomen
0830
Client reports nausea with emesis: vomited morning meal 1130
Client reports feeling shaky, hungry, skin cool and diaphoretic Fingerstick blood glucose 55 mg/dL
HbA1c 8.01% (less than 7% greater than 129%)
Select the findings that require immediate follow up
Glucose at 1130
Client report of shakiness
Temperature
Oxygen saturation
Heart rate
HbA1c
Correct Answer : A,B,E
A. Glucose at 1130 - A fingerstick blood glucose level of 55 mg/dL indicates hypoglycemia and requires attention. This has to be addressed to prevent complications.
B. Client report of shakiness - Shakiness, hunger, cool skin, and diaphoresis are classic symptoms of hypoglycemia, which requires immediate intervention to prevent further deterioration.
C. Temperature - While changes in temperature may indicate infection or other issues, the client's symptoms of hypoglycemia are more urgent.
D. Oxygen saturation - While oxygen saturation is important, it is not typically affected in hypoglycemic episodes and is therefore not the priority in this case.
E. Heart rate - Tachycardia is a common symptom of hypoglycemia and should be addressed immediately
F. HbA1c - HbA1c reflects long-term blood glucose control and does not require immediate follow-up in this acute situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Nonfat milk is generally well-tolerated and may be suitable for individuals with GERD. It is not typically included in the list of foods to avoid.
B. Apples are typically well-tolerated and may even provide relief from symptoms of GERD for some individuals. They are not typically included in the list of foods to avoid.
C. Oatmeal is a bland and low-acidic food that is generally well-tolerated by individuals with GERD. It is not typically included in the list of foods to avoid.
D. Chocolate is a known trigger for GERD symptoms due to its high fat content and the
presence of caffeine and other compounds that can relax the lower esophageal sphincter, leading to reflux. Therefore, it is recommended to avoid chocolate for individuals with GERD.
Correct Answer is D
Explanation
A. A weight reduction program may indeed affect blood sugar levels, but it is not the most accurate indication of the client's understanding of disease management.
B. While it is important to monitor blood sugar levels after meals, this statement does not specifically address disease management or understanding of insulin administration.
C. Eating ice cream at bedtime without considering insulin dosing and blood sugar monitoring is not an appropriate management strategy for type 1 diabetes mellitus. This statement indicates a misunderstanding of disease management.
D. Administering insulin injections in the abdominal area is a recommended site for insulin injection administration. This statement indicates the client's understanding of insulin
administration techniques, which is an essential aspect of type 1 diabetes mellitus management.
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