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A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client's clinical manifestations have not changed. Which action should the nurse take next?
- A. Administer another half-cup of orange juice.
- B. Administer a half-ampule of dextrose 50%.
- C. Administer 10 units of regular insulin subcutaneously.
- D. Administer 1 mg of glucagon intramuscularly.
Correct Answer: A
Rationale: The client has mild hypoglycemia, and since the initial orange juice did not resolve symptoms, repeating the oral glucose treatment is appropriate. Intravenous dextrose, insulin, or glucagon are not indicated for mild, unresolved symptoms in an alert client.
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A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The client's blood glucose level is 160 mg/dL. Which action should the nurse take?
- A. Document the finding in the client's chart.
- B. Administer a bolus of regular insulin IV.
- C. Call the surgeon to cancel the procedure.
- D. Draw blood gases to assess the metabolic state.
Correct Answer: A
Rationale: A blood glucose of 160 mg/dL is within the acceptable range (140"?180 mg/dL) for perioperative management in type 1 diabetes, supporting better outcomes. The nurse should document the finding and proceed. Insulin, cancellation, or blood gases are not indicated.
A nurse cares for a client who has type 1 diabetes mellitus. The client asks, 'Is it okay for me to have an occasional glass of wine?' How should the nurse respond?
- A. Drinking any wine or alcohol will increase your insulin requirements.
- B. Because of poor kidney function, people with diabetes should avoid alcohol.
- C. You should not drink alcohol because it will make you hungry and overeat.
- D. One glass of wine is okay with a meal and is counted as two fat exchanges.
Correct Answer: D
Rationale: Moderate alcohol, like one glass of wine with a meal, is acceptable for well-controlled diabetes and is counted as two fat exchanges. Alcohol does not directly increase insulin needs, affect kidney function in this context, or necessarily cause overeating.
A nurse is teaching a client with diabetes mellitus who asks, 'Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL?' How should the nurse respond?
- A. Glucose is the only fuel used by the body to produce the energy that it needs.
- B. Your brain needs a constant supply of glucose because it cannot store it.
- C. Without a minimum level of glucose, your body does not make red blood cells.
- D. Glucose in the blood prevents the formation of lactic acid and prevents acidosis.
Correct Answer: B
Rationale: Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system. The nurse should educate the client to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not directly involved in the production of red blood cells. Glucose in the blood does not directly prevent lactic acid formation.
After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
- A. The lower abdomen is the best location because it is closest to the pancreas.
- B. I can reach my thigh the best, so I will use the different areas of my thighs.
- C. By rotating the sites in one area, my chance of having a reaction is decreased.
- D. Changing injection sites from the thigh to the arm will change absorption rates.
Correct Answer: A
Rationale: The abdominal site has the fastest insulin absorption due to its blood supply, not proximity to the pancreas. The other statements are accurate regarding site rotation and absorption rates.
A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has a capillary blood glucose of 33 mg/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first?
- A. Administer 1 mg of intramuscular glucagon.
- B. Encourage the client to drink orange juice.
- C. Insert a new intravenous access line.
- D. Administer 25 mL dextrose 50% (D50) IV push.
Correct Answer: A
Rationale: The client's severe hypoglycemia (blood glucose 33 mg/dL) and unresponsiveness require immediate treatment. Intramuscular glucagon is the priority since the IV line is infiltrated, and oral intake is not feasible. Inserting a new IV or administering D50 IV can follow once access is restored.