The nurse is evaluating care provided to a patient with type 2 diabetes mellitus. Which data indicates that the patient is managing the disease process effectively?
Weight gain of 3 lbs. over the last 2 months
Eye doctor appointment scheduled for the following week
Hemoglobin A1c level 8.1%
Reddened area noted on the sole of the left foot
The Correct Answer is B
A. Incorrect → Weight gain (even if minor) can indicate poor glucose control, especially if linked to fluid retention or insulin resistance.
B. Regular ophthalmology exams are crucial for early detection of diabetic retinopathy, a leading cause of blindness in diabetes. Scheduling an eye appointment demonstrates proactive disease management.
C. Incorrect → A Hemoglobin A1c of 8.1% is above the target range (typically <7% for diabetics) and indicates poor blood glucose control over the past 2-3 months.
D. Incorrect → A reddened area on the sole of the foot suggests early signs of diabetic foot complications and possible neuropathy or poor circulation, requiring intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain a prescription for supplemental oxygen. – Correct Answer. Hypoxia must be corrected first to prevent tissue hypoxia and organ failure.
B. Obtain a prescription to administer intravenous fluids. – Incorrect. IV fluids are important but oxygenation is the priority.
C. Obtain a prescription to administer insulin. – Incorrect. Insulin corrects hyperglycemia but is not the first priority over oxygenation.
D. Obtain a prescription to check the patient’s glucose level. – Incorrect. While glucose monitoring is essential, treating hypoxia takes priority.
Correct Answer is B
Explanation
A. Infuse the transfusion at a rate of 200 mL/hr. – Incorrect. The initial infusion should be slow (e.g., 75-100 mL/hr) to monitor for reactions.
B. Check the patient's vital signs every hour during the transfusion. – Correct Answer. Frequent monitoring is necessary to detect adverse reactions, such as fever or hypotension.
C. Leave the patient 5 minutes after beginning the transfusion. – Incorrect. The nurse should remain with the patient for the first 15 minutes, as most transfusion reactions occur early.
D. Flush the blood tubing with dextrose 5% in water. – Incorrect. Only normal saline should be used to flush blood tubing, as dextrose can cause hemolysis.
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