The nurse is admitting a patient with type 1 diabetes. While reviewing the patient's laboratory results, the nurse notes the presence of ketones in the urine. What intervention will the nurse implement for this patient?

Advise the patient to consume protein and carbohydrates immediately.

Notify the provider of the result and recommend that the patient's insulin dose be increased.

Instruct the patient to withhold the next scheduled dose of insulin.

Suggest that the patient asks their provider to start them on metformin therapy.

Answer and Explanation

The Correct Answer is B

Choice A reason: Advising the patient to consume protein and carbohydrates immediately is not appropriate in this context. The presence of ketones in the urine indicates that the body is using fat for energy due to a lack of insulin. Increasing carbohydrate intake without addressing the underlying insulin deficiency can worsen hyperglycemia and ketoacidosis.

Choice B reason: Notifying the provider of the result and recommending that the patient's insulin dose be increased is the appropriate intervention. The presence of ketones in the urine indicates inadequate insulin levels, and adjusting the insulin dose can help correct the metabolic imbalance and prevent further complications such as diabetic ketoacidosis.

Choice C reason: Instructing the patient to withhold the next scheduled dose of insulin is incorrect. Insulin is essential for managing blood glucose levels and preventing ketosis in patients with type 1 diabetes. Withholding insulin can lead to severe hyperglycemia and ketoacidosis.

Choice D reason: Suggesting that the patient ask their provider to start them on metformin therapy is not appropriate for type 1 diabetes. Metformin is used primarily for type 2 diabetes and is not effective in type 1 diabetes, where insulin is required for glucose management.

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Correct Answer is A

Explanation

Choice A reason: Removal of the transplanted kidney is the definitive intervention for hyperacute rejection. Hyperacute rejection occurs within minutes to hours after transplantation due to pre-formed antibodies against the donor organ. This form of rejection is irreversible and requires immediate removal of the transplanted kidney to prevent further complications and damage to the recipient's health.

Choice B reason: An increase in the dose of cyclosporine therapy is not effective in hyperacute rejection. Cyclosporine is an immunosuppressive medication used to prevent rejection, but in cases of hyperacute rejection, the rapid and severe immune response cannot be controlled by increasing the dose. The affected kidney must be removed.

Choice C reason: A new kidney transplant from a living donor is not an immediate intervention for hyperacute rejection. Before considering another transplant, it is essential to identify and address the underlying cause of hyperacute rejection and ensure that the recipient's immune system is adequately managed to prevent recurrence.

Choice D reason: Administration of methylprednisolone sodium succinate is typically used to manage acute rejection episodes but is not effective for hyperacute rejection. The rapid onset and severity of hyperacute rejection necessitate the removal of the transplanted organ rather than relying on immunosuppressive medications.

A. The patient who is having white milky liquid stools immediately after a barium enema. B. The patient with irritable bowel syndrome (IBS) who has not had a bowel movement for three days. C. The patient diagnosed with ulcerative colitis with a temperature of 101°F and abdominal distention. D. The patient receiving Total Parenteral Nutrition (TPN) whose blood glucose level is 225 mg/dL.

Correct Answer is C

Explanation

Choice A reason: White milky liquid stools immediately after a barium enema are not uncommon and are typically due to the passage of barium. This finding does not usually require immediate reporting unless there are other concerning symptoms.

Choice B reason: Not having a bowel movement for three days in a patient with irritable bowel syndrome (IBS) can be uncomfortable but is not typically an emergency. Management can be addressed through dietary and medication adjustments rather than immediate reporting.

Choice C reason: A temperature of 101°F and abdominal distention in a patient diagnosed with ulcerative colitis is concerning and should be reported immediately. These symptoms can indicate a serious complication such as toxic megacolon, perforation, or severe infection, which require prompt medical intervention.

Choice D reason: A blood glucose level of 225 mg/dL in a patient receiving Total Parenteral Nutrition (TPN) is elevated but not necessarily an emergency. Elevated blood glucose levels are a common side effect of TPN and can be managed through adjustments in insulin or TPN composition.

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The nurse is admitting a patient with type 1 diabetes. While reviewing the patient's laboratory results, the nurse notes the presence of ketones in the urine. What intervention will the nurse implement for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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