An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair.
The patient reports feeling very weak and jittery.
What actions should the nurse take? (Select all that apply)
Check fingerstick glucose level.
Assess skin temperature and moisture.
Administer a PRN dose of regular insulin.
Document anxiety on the surgical checklist.
Measure pulse and blood pressure.
Correct Answer : A,B,E
Choice A rationale
Checking the fingerstick glucose level is an immediate action that the nurse should take when a patient with type 2 diabetes reports feeling weak and jittery. These symptoms could indicate hypoglycemia, a condition characterized by low blood sugar levels.
Choice B rationale
Assessing skin temperature and moisture can help the nurse determine if the patient is sweating, a common symptom of hypoglycemia.
Choice C rationale
Administering a PRN dose of regular insulin is not the appropriate action if the patient is experiencing symptoms of hypoglycemia. Insulin would further lower the patient’s blood sugar levels, potentially worsening their condition.
Choice D rationale
Documenting anxiety on the surgical checklist may not be immediately helpful in addressing the patient’s current symptoms. While it’s important to document all relevant information, the nurse’s immediate focus should be on assessing and managing the patient’s symptoms.
Choice E rationale
Measuring pulse and blood pressure can provide important information about the patient’s cardiovascular status. Hypoglycemia can cause tachycardia and potentially hypotension, so these vital signs should be monitored.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
While spicy foods can irritate the urinary tract, they do not have a direct impact on the care and management of an indwelling urinary catheter after a TURP3.
Choice B rationale
Drinking 3 liters of water each day is important as it helps flush the bladder and reduce the risk of urinary tract infections, which are a common complication after a TURP3.
Choice C rationale
Clamping the catheter is not typically recommended as it can lead to urinary retention and increase the risk of urinary tract infections.
Choice D rationale
Avoiding driving for 2 weeks is a general recommendation after any major surgery to allow the body time to heal, but it does not directly relate to the care of an indwelling urinary catheter.
Correct Answer is B
Explanation
Choice A rationale
While it’s important to keep the feet moisturized to prevent skin cracks, this statement does not indicate that the client understands how to prevent complications related to diabetes mellitus.
Choice B rationale
Using salt, herbs, and spices to enhance the flavor of foods can be a part of a healthy diet, which is crucial in managing diabetes. This statement indicates that the client understands the importance of dietary management in preventing complications related to diabetes mellitus.
Choice C rationale
While moderate alcohol consumption may be acceptable for some people with diabetes, it’s not a key factor in preventing complications related to diabetes mellitus.
Choice D rationale
While regular monitoring of blood glucose control through tests like the A1C is important, this statement alone does not indicate that the client understands how to prevent complications related to diabetes mellitus.
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