A nurse is caring for a client who has type 1 diabetes mellitus.
Which of the following conditions should the nurse monitor the client for due to the client's lack of insulin production?
Hypoglycemia.
Neuroglycopenia.
Increased glycogen storage.
Diabetic ketoacidosis (DKA).
The Correct Answer is D
Choice A rationale
Hypoglycemia is generally a complication of diabetes treatment, such as excessive insulin administration or inadequate carbohydrate intake, rather than a direct result of the disease process itself. In type 1 diabetes, the primary physiological issue is the autoimmune destruction of beta cells, leading to a total lack of endogenous insulin. Without external insulin, blood glucose levels will rise, not fall. Therefore, the nurse monitors for hypoglycemia primarily as a side effect of the exogenous insulin therapy provided.
Choice B rationale
Neuroglycopenia refers to a shortage of glucose in the brain, which usually occurs when blood glucose levels fall below 50 mg/dL. While this is a serious concern for patients with type 1 diabetes who are receiving insulin, it is not the direct result of a lack of insulin production. In fact, a lack of insulin results in hyperglycemia, where there is plenty of glucose in the blood but it cannot enter the cells. Neuroglycopenia is a symptom of the treatment, not the underlying deficiency.
Choice C rationale
Insulin is the primary hormone responsible for glycogenesis, which is the conversion of glucose into glycogen for storage in the liver and muscles. In a client with type 1 diabetes, the absolute lack of insulin prevents the body from storing glucose effectively. Instead of increased storage, the body undergoes glycogenolysis and gluconeogenesis to further increase blood sugar levels. Thus, the nurse would expect to see depleted glycogen stores rather than an increase in storage due to the insulin deficit.
Choice D rationale
Diabetic ketoacidosis is a life threatening complication directly caused by an absolute lack of insulin in type 1 diabetes. Without insulin, the body cannot use glucose for energy and begins breaking down fats. This process produces acidic ketones, leading to metabolic acidosis. Clinical signs include Kussmaul respirations and a fruity breath odor. Laboratory findings typically show a blood glucose greater than 250 mg/dL, a serum bicarbonate less than 18 mEq/L, and a pH less than 7.30.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Suction equipment is primarily utilized for maintaining a patent airway when a client is unable to clear secretions independently due to a diminished cough reflex or neurological impairment. While essential for airway management in specific populations, it does not actively prevent pulmonary complications like atelectasis or pneumonia in the typical postoperative client. Instead, it serves as a reactive measure to clear existing obstructions rather than a proactive strategy for lung expansion.
Choice B rationale
Range-of-motion exercises are vital interventions for preventing musculoskeletal stiffness and reducing the risk of deep vein thrombosis by promoting venous return in the extremities. While these exercises improve overall circulation, they do not directly target the alveolar expansion required to prevent postoperative pulmonary issues. Pulmonary care specifically requires maneuvers that increase intrathoracic pressure or facilitate deep breathing to ensure that the lower lobes of the lungs remain well-ventilated during the recovery period.
Choice C rationale
An incentive spirometer encourages voluntary deep breathing by providing visual feedback, which helps the client achieve maximum inspiratory concentration. This process promotes alveolar expansion and prevents atelectasis, which is the collapse of lung tissue commonly seen after general anesthesia. By increasing transpulmonary pressure and inspiratory volumes, it facilitates the clearance of secretions and improves gas exchange. Regular use is a cornerstone of postoperative care to decrease the incidence of hospital-acquired pneumonia.
Choice D rationale
Expectorants are pharmacological agents designed to reduce the viscosity of secretions, making them easier to cough up and expel from the respiratory tract. While they can be helpful if a client has thick, tenacious mucus, they are not a standard preventive intervention for all postoperative clients. Over-reliance on medication without mechanical lung expansion exercises fails to address the underlying risk of shallow breathing and lung collapse caused by anesthesia and postoperative pain.
Correct Answer is ["50"]
Explanation
Step 1 is (150 mL × 20 gtt ÷ mL) ÷ 60 min.
Step 2 is 3000 gtt ÷ 60 min.
Step 3 is 50 gtt ÷ min. The final calculated answer is 50.
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