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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.
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A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first?
- A. Document the finding in the client's chart.
- B. Assess tactile sensation in the client's hands.
- C. Examine the client's feet for signs of injury.
- D. Notify the health care provider.
Correct Answer: C
Rationale: Diabetic neuropathy is common in long-standing diabetes, increasing the risk of injury in areas with decreased sensation, such as the feet. Examining the feet for signs of injury is the priority to prevent complications like infections or ulcers. Documentation, assessing hand sensation, and notifying the provider should follow after the initial assessment.
A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this client's teaching to prevent bloodborne infections?
- A. Wash your hands after completing each test.
- B. Do not share your monitoring equipment.
- C. Wipe excess blood from the strip with a cotton ball.
- D. Use gloves when monitoring your blood glucose.
Correct Answer: B
Rationale: Sharing monitoring equipment can transmit bloodborne infections like hepatitis B, which can survive in dried blood. Not sharing equipment is critical. Washing hands before testing, not after, is recommended. Wiping blood with a cotton ball or using gloves is not standard practice for preventing infections.
A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. The client states, 'I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing.' How should the nurse respond?
- A. Following-Drug regimen more closely would have prevented this.
- B. One acute rejection episode does not mean that you will lose the new organs.
- C. Dialysis is a viable treatment option for you and may save your life.
- D. Since you are on the national registry, you can receive a second transplantation.
Correct Answer: B
Rationale: An acute rejection episode does not necessarily lead to organ loss, as immunosuppressive therapy can often manage it. Blaming the client, emphasizing dialysis, or discussing retransplantation is not supportive or accurate in this context.
A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately?
- A. Serum chloride level of 98 mmol/L.
- B. Serum calcium level of 8.8 mg/dL.
- C. Serum sodium level of 132 mmol/L.
- D. Serum potassium level of 2.5 mmol/L.
Correct Answer: D
Rationale: Insulin promotes potassium movement into cells, risking hypokalemia (2.5 mmol/L is low). This requires immediate intervention to prevent complications like arrhythmias. The other values are near normal and not directly related to insulin therapy.
A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications?
- A. Maintain tight glycemic control and prevent hyperglycemia.
- B. Prevent hypoglycemia with insulin.
- C. Restrict your fluid intake to no more than 2 liters a day.
- D. Limit your intake of protein to prevent ketoacidosis.
Correct Answer: A
Rationale: Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control helps delay the onset of microvascular and macrovascular complications. Fluid restriction, preventing hypoglycemia, and limiting protein are not the primary strategies for this goal.