An adult patient with type 2 diabetes mellitus (DM2) is due to be admitted to the medical unit from the emergency department within the next hour.
The patient’s lab results show that the serum glucose is 175 mg/dL (9.63 mmol/L) and the A1c is 9%. Which meal option should the nurse request for the patient’s dinner tray?

Choice A rationale
Testing the fluid on the dressing for glucose is the immediate course of action when a nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. Clear fluid could be cerebrospinal fluid (CSF), which contains glucose. If the fluid is positive for glucose, it could indicate a CSF leak, which requires immediate medical attention.
Choice B rationale
Changing the dressing using a compression bandage is not the immediate course of action. The source of the fluid needs to be identified first.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate course of action. The source of the fluid needs to be identified first.
Choice D rationale
Documenting the findings in the electronic medical record is important, but it is not the immediate course of action. The source of the fluid needs to be identified first.

Choice A rationale
Anticipating and monitoring for hypothermia is the most crucial nursing intervention to include in the care plan for a patient who is 12 hours post-thyroidectomy. The thyroid gland plays a significant role in regulating the body’s metabolism, including temperature regulation. After a thyroidectomy, the body may struggle to regulate temperature, leading to hypothermia. The nurse should monitor the patient’s temperature regularly and provide warming measures as needed.

Choice B rationale
Preparing to administer radioactive iodine treatments is not the most crucial intervention at this time. Radioactive iodine is typically used as a treatment for hyperthyroidism or thyroid cancer, not as an immediate post-operative intervention.

Choice C rationale
Resuming antithyroid drug therapy is not the most crucial intervention at this time. Antithyroid drugs are used to treat hyperthyroidism, and their use would need to be evaluated based on the reason for the thyroidectomy and the patient’s post-operative thyroid hormone levels.

Choice D rationale
Maintaining a semi-Fowler position can be beneficial for comfort and respiratory function post-operatively, but it is not the most crucial intervention. The nurse should assist the patient to a comfortable position and encourage regular deep breathing and coughing exercises to prevent respiratory complications.