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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
For a client with emphysema who will be discharged with oxygen, understanding the guidelines for oxygen use is crucial. Misuse of oxygen can lead to serious health complications, so it’s important that the client knows how to use it correctly.
Choice B rationale
While energy conservation approaches can be beneficial for a client with emphysema, they are not as crucial as understanding the guidelines for oxygen use.
Choice C rationale
While smoking cessation strategies are important for a client with emphysema, especially one who smokes heavily, they are not as crucial as understanding the guidelines for oxygen use.
Choice D rationale
While weight loss methods can be beneficial for an obese client, they are not as crucial as understanding the guidelines for oxygen use for a client with emphysema who will be discharged with oxygen.
Correct Answer is B
Explanation
Choice A rationale
Latent hepatitis C is not a contraindication for peritoneal dialysis. While it may require additional monitoring and treatment, it does not prevent a patient from receiving peritoneal dialysis.
Choice B rationale
Crohn’s disease with colectomy is a contraindication for peritoneal dialysis. The presence of extensive adhesions and fibrosis from the surgery can make the peritoneum unsuitable for dialysis.
Choice C rationale
A history of nephrotic syndrome is not a contraindication for peritoneal dialysis. Nephrotic syndrome is a kidney disorder, and peritoneal dialysis can be used as a treatment for patients with kidney disease.
Choice D rationale
Type 2 diabetes mellitus is not a contraindication for peritoneal dialysis. Many patients with diabetes undergo peritoneal dialysis. However, careful monitoring of blood glucose levels is necessary, as the dialysis solution used in peritoneal dialysis contains glucose.
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