Nokea
During change of shifts, a nurse discovers that a hospitalized client with diabetes received two doses of insulin. After notifying the physician, which nursing action is most appropriate?
- A. Completing an incident report
- B. Calling the intensive care unit (ICU)
- C. Performing frequent neurologic checks
- D. Monitoring the client's blood glucose level
Correct Answer: D
Rationale: Monitoring blood glucose is critical to detect and manage potential hypoglycemia from the double dose.
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The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement?
- A. Provide a high-fat diet 24 hours prior to test.
- B. Hold the biguanide medication for 48 hours prior to test.
- C. Obtain an informed consent form for the test.
- D. Administer pancreatic enzymes prior to the test.
Correct Answer: B
Rationale: Biguanides (e.g., metformin) are held 48 hours before contrast CT to prevent lactic acidosis due to contrast-induced kidney injury. High-fat diets, consent, and enzymes are irrelevant.
If the screening includes a measurement of postprandial blood glucose, the nurse is correct in explaining that blood will be drawn at which time?
- A. Approximately 2 hours before breakfast
- B. Approximately 2 hours after a meal
- C. Approximately 2 hours before bedtime
- D. Approximately 2 hours after fasting
Correct Answer: B
Rationale: Postprandial blood glucose is measured 2 hours after a meal to assess glucose metabolism.
Which nursing intervention is essential for monitoring the client's condition?
- A. Measuring intake and output
- B. Muxying blood glucose levels
- C. Inserting a Foley catheter
- D. Sending urine samples to the laboratory
Correct Answer: A
Rationale: Monitoring intake and output is critical in diabetes insipidus to assess fluid balance and the severity of polyuria.
Which I.V. medication can the nurse expect the physician to order to treat the client's condition?
- A. Calcium gluconate
- B. Ferrous sulfate
- C. Potassium chloride
- D. Sodium bicarbonate
Correct Answer: A
Rationale: Calcium gluconate is used to treat tetany caused by hypocalcemia in hypoparathyroidism.
Which laboratory data indicate to the nurse the client’s pancreatitis is improving?
- A. The amylase and lipase serum levels are decreased.
- B. The white blood cell (WBC) count is decreased.
- C. The conjugated and unconjugated bilirubin levels are decreased.
- D. The blood urea nitrogen (BUN) serum level is decreased.
Correct Answer: A
Rationale: Acute pancreatitis is characterized by elevated serum amylase and lipase levels due to pancreatic inflammation. A decrease in these levels indicates reduced pancreatic injury and improvement in the condition. While a decreased WBC count may suggest resolving infection, it is less specific. Bilirubin levels are relevant for biliary obstruction, not pancreatitis improvement, and BUN reflects renal function, not pancreatic status.