The nurse administers regular insulin SUBQ at 0700 to a client with type 1 diabetes mellitus (DM), after which the client eats one-half of the breakfast provided. At 1000, the client reports being hungry. Which action should the nurse implement?
Administer insulin per sliding scale.
Start hourly blood glucose monitoring.
Initiate an IV bolus of 0.9% sodium chloride.
Provide a snack of cheese and crackers.
The Correct Answer is D
Choice A reason: Administering insulin per sliding scale is typically based on blood glucose levels, not just the client's report of hunger. Since the client has already received insulin, providing more insulin without knowing the current blood glucose level could cause hypoglycaemia.
Choice B reason: Starting hourly blood glucose monitoring might be necessary in certain situations, but the immediate need is to address the client's hunger, which could be a sign of impending hypoglycaemia. Addressing the hunger first is more urgent.
Choice C reason: Initiating an IV bolus of 0.9% sodium chloride is not indicated in this scenario. This intervention is typically used for dehydration or other fluid imbalances, not for managing hunger or blood glucose levels directly.
Choice D reason: Providing a snack of cheese and crackers is the most appropriate action. The client's report of hunger after receiving insulin and eating only half of breakfast suggests they might be at risk for hypoglycaemia. A snack will help stabilize their blood glucose levels and prevent hypoglycaemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Crackles or coarse rales are typically associated with fluid in the airways, such as in cases of congestive heart failure or pneumonia, but they do not directly indicate a pleural effusion.
Choice B reason: A pleural friction rub is associated with pleuritis, where the inflamed pleurae rub against each other. It does not indicate decreased air flow in a specific lobe.
Choice C reason: Low pitched, sonorous rhonchi are related to secretions in the larger airways and are not specific to a pleural effusion or decreased air flow in one lobe.
Choice D reason: Diminished breath sounds in the left upper lobe are consistent with a pleural effusion, as the fluid can reduce air flow and sound transmission in that area. This finding directly correlates with the x-ray results showing decreased air flow in the entire left upper lobe.
Correct Answer is B
Explanation
Choice A reason: Drinking several bottles of carbonated water daily is not a well-established risk factor for renal calculi. While hydration is important in preventing kidney stones, carbonation itself does not significantly increase the risk.
Choice B reason: Eating a vegetarian diet with cheese 2 to 3 times a day can increase the risk for kidney stones, especially if the cheese is high in calcium or oxalates. Dairy products, including cheese, contain calcium, and excessive consumption can contribute to the formation of calcium oxalate stones, which are the most common type of kidney stones.
Choice C reason: Experiencing additional stress since adopting a child is not directly related to the formation of kidney stones. Stress can have various health impacts, but it is not a known primary risk factor for renal calculi.
Choice D reason: Jogging more frequently than the usual daily routine is not associated with an increased risk of kidney stones. Regular physical activity is generally beneficial for overall health and does not contribute to the formation of renal calculi.
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