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?

Choice A rationale

Tarry stools are not a typical manifestation of cirrhosis. They are more commonly associated with gastrointestinal bleeding.

Choice B rationale

Spider angiomas are a common manifestation of cirrhosis. They are small, dilated blood vessels with a bright red center point and radiating branches, and they are often found on the face, neck, and chest.

Choice C rationale

Moist skin is not a typical manifestation of cirrhosis. Cirrhosis can cause various skin changes, but they typically include jaundice, pruritus, and palmar erythema.

Choice D rationale

Blood in the urine is not a typical manifestation of cirrhosis. It is more commonly associated with urinary tract infections, kidney stones, or bladder disorders.

Choice A rationale

While it is important to notify the doctor, it is not the first action. The priority is to manage the patient’s symptoms and ensure their safety.

Choice B rationale

Administering diazepam is the correct first action. Delirium tremens is a severe form of alcohol withdrawal that can cause dangerous changes in breathing, blood pressure, and heart rate. Benzodiazepines like diazepam are the first line of treatment.

Choice C rationale

Obtaining a medical history is important, but it is not the first action. The priority is to treat the patient’s symptoms and stabilize their condition.

Choice D rationale

Raising the side rails of the bed is important for patient safety, but it is not the first action. The priority is to treat the patient’s symptoms. Diabetic ketoacidosisDiabetic ketoacidosis Explore