Nokea
The nurse caring for a diabetes mellitus client obtained a scheduled capillary blood glucose. The result indicated 40 mg/dL (2.22 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. The client reports no symptoms. The initial action of the nurse should be which of the following?
- A. Document the finding in the medical record
- B. Repeat the capillary blood glucose test to validate the result
- C. Administer 15 grams of a quick-acting carbohydrate
- D. Administer 1 mg of glucagon subcutaneously
Correct Answer: B
Rationale: A glucose of 40 mg/dL is critically low, even without symptoms. Repeating the test validates the result, ensuring accuracy before treatment to avoid unnecessary intervention.
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The nurse is performing a physical assessment on a client with Cushing's disease. Which assessment findings should the nurse expect?
- A. Hypotension
- B. Acne
- C. Hirsutism
- D. Buffalo hump
- E. Truncal obesity
Correct Answer: B, C, D, E
Rationale: Cushing's disease from excess cortisol causes acne, hirsutism (excess hair), buffalo hump, and truncal obesity due to fat redistribution. Hypertension, not hypotension, is typical.
The nurse has instructed a client scheduled for an injection of dulaglutide for diabetes mellitus (type two). Which of the following statements by the client would require follow-up?
- A. I should tell my doctor if I experience abdominal pain and vomiting.
- B. I should take this medication within one hour of eating a meal.
- C. If this medication works, I should notice a reduction in my hemoglobin A1C (HbA1c).
- D. I will receive this medication once a week.
Correct Answer: B
Rationale: Dulaglutide, a GLP-1 agonist, is taken weekly regardless of meals, not within one hour of eating. Abdominal pain/vomiting should be reported, HbA1c reduction is expected, and weekly dosing is correct.
A nurse is caring for a client receiving metformin. Which of the following laboratory data should be reported to the provider?
- A. Decreased blood urea nitrogen (BUN) level
- B. Decreased glomerular filtration rate (GFR)
- C. Decreased fasting plasma glucose
- D. Decreased hemoglobin A1C
Correct Answer: B
Rationale: A decreased GFR indicates renal impairment, increasing the risk of metformin-associated lactic acidosis, requiring immediate reporting. Decreased BUN, glucose, and HbA1c are expected or less urgent.
The nurse is caring for a client with diabetic ketoacidosis (DKA) who is receiving an infusion of regular insulin. Which of the following clinical data should be reported to the primary healthcare provider (PHCP) immediately?
- A. Glucose 297 mg/dL, 16.52 mmol/L (70-110 mg/dL, 4.0-11.0 mmol/L)
- B. Potassium 3.2 mEq/L, 3.2 mmol/L (3.5-5 mEq/L, 3.5-5.1 mmol/L)
- C. BUN 24 mg/dL, 8.568 mmol/L (10-20 mg/dL, 2.5 to 6.4 mmol/L)
- D. Hemoglobin A1C 8.9% ( < 7%, 4.8%-6.0%)
Correct Answer: B
Rationale: In DKA, insulin shifts potassium into cells, risking hypokalemia. A level of 3.2 mEq/L is critical and needs immediate reporting to prevent arrhythmias. Glucose, BUN, and HbA1C are monitored but less urgent.
The nurse is reviewing endocrine disorders with a group of students. It would be correct for the nurse to identify which manifestation is associated with hyperthyroidism?
- A. Injected (red) conjunctiva
- B. Insomnia
- C. Increased systolic blood pressure
- D. Diaphoresis
- E. Confusion
Correct Answer: B, C, D
Rationale: Hyperthyroidism increases metabolism, causing insomnia, elevated systolic BP, and sweating (diaphoresis). Red conjunctiva and confusion are not typical features of this condition.