A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing:

Type 1 diabetes

Actions to Take:

Teach the client about the signs of hyperglycemia.
Assess the client’s feet for sensation.

Parameters to Monitor:

Fingerstick blood glucose
Blood pressure

Rationale: The client has a high HbA1c (8.4%) and elevated blood glucose level (235 mg/dL), indicating poor blood glucose control. Symptoms such as fatigue, blurred vision, and dizziness suggest hyperglycemia, which can occur in clients with diabetes who have not been able to maintain regular glucose monitoring or insulin administration due to financial constraints. Teaching the client about hyperglycemia symptoms and checking feet for sensation is important due to the risk of complications like neuropathy. Monitoring blood glucose and blood pressure is essential for evaluating diabetes management and preventing complications.

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Free Nursing Study Resources

Correct Answer is ["A","B","E","F"]

Explanation

A. Tachycardia is a common response to hypoglycemia due to the body's release of adrenaline.
B. Diaphoresis is also associated with hypoglycemia and results from sympathetic nervous system activation.
C. Frequent urination is a symptom of hyperglycemia, not hypoglycemia.
D. Thirst also indicates hyperglycemia, not hypoglycemia.
E. Hunger is a common sign of hypoglycemia as the body signals the need for glucose.
F. Shakiness is a symptom of hypoglycemia due to adrenaline release.

Correct Answer is ["56"]

Explanation

To calculate the flow rate for an IV bolus of Ringer's lactate to be infused over 3 hours, you would use the formula: (Volume in mL * Drop factor) / Time in minutes. For 500 mL of Ringer's lactate with a drop factor of 20 gtt/mL over 180 minutes (3 hours), the calculation would be (500 * 20) / 180, which equals 55.55. Rounding to the nearest whole number, the nurse should set the manual IV infusion to deliver 56 gtt/min.

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)

Correct Answer is ["A","B","E","F"]

Explanation

Correct Answer is ["56"]

Explanation

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