A nurse is caring for a patient with diabetes and plans to administer regular insulin subcutaneously before breakfast at 0800.
After checking the patient’s morning glucose level, what action should the nurse take?

Potential Condition:

• B. Type 1 diabetes mellitus

The client’s symptoms of fatigue, blurred vision, dizziness, and headache, along with a high blood glucose level and HbA1C, suggest that they are experiencing hyperglycemia, a condition common in individuals with Type 1 diabetes mellitus.

Actions to Take:

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

Teaching the client about the signs of hyperglycemia will help them recognize when their blood sugar is high and take appropriate action. Assessing the client’s feet for sensation is also important as diabetes can lead to peripheral neuropathy, which can result in a loss of sensation in the feet.

Parameters to Monitor:

• B. Blood pressure
• D. Fingerstick blood glucose

Monitoring the client’s blood pressure is important as hypertension can be a complication of diabetes. Regularly checking the client’s fingerstick blood glucose levels will help ensure that their diabetes is being effectively managed.

Choice A rationale

Cheyne-Stokes breathing, characterized by a cycle of increasing and decreasing respiratory rate and depth, is not a typical symptom of diabetic ketoacidosis (DKA). DKA is more commonly associated with Kussmaul breathing, which is rapid, deep, and labored.

Choice B rationale

An acetone odor to the breath is a classic symptom of DKA. This is due to the body breaking down fat for energy, which produces ketones. These ketones can cause the breath to smell fruity or like nail polish remover.

Choice C rationale

A blood glucose level below 40 mg/dL is not a symptom of DKA. In fact, DKA is characterized by high blood glucose levels, typically above 250 mg/dL111213.

Choice D rationale

Malignant hypertension is not a typical symptom of DKA. While DKA can cause dehydration and electrolyte imbalances that may affect blood pressure, it does not typically cause malignant hypertension.