Nokea
The nurse is caring for multiple clients with DM. It is most important for the nurse to initiate a referral to a diabetes educator for which client?
- A. The client who states diabetes is well controlled with diet and exercise; Hgb A1c is 11%.
- B. The client requesting diabetes information; fingerstick glucose is 132 mg/dL, Hgb A1c is 5.6%.
- C. The client who states perfect compliance with diet, exercise, and meds; Hgb A1c is 7%.
- D. The client with short-term memory loss; fingerstick glucose is 110 mg/dL, Hgb A1c is 4.5%.
Correct Answer: A
Rationale: It is most important for the nurse to initiate a referral for clients who falsely think their diabetes is well controlled. The client's Hgb A1c, which measures average blood glucose over the previous 3 months, is 11%, indicating that the diabetes is not well controlled.
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The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes?
- A. Eat a simple carbohydrate snack before exercising.
- B. Carry peanut butter crackers when exercising.
- C. Encourage the client to walk 20 minutes three (3) times a week.
- D. Perform warm-up and cool-down exercises.
Correct Answer: D
Rationale: Warm-up and cool-down exercises prevent injury during exercise, crucial for type 2 diabetics. Pre-exercise snacks are for insulin users, peanut butter is high-fat, and walking is good but not the focus.
Which finding indicates a potential complication of thyroid crisis that the nurse should prioritize?
- A. Heart rate of 140 beats per minute
- B. Blood pressure of 120/80 mmHg
- C. Temperature of 98.6°F
- D. Respiratory rate of 16 breaths per minute
Correct Answer: A
Rationale: A heart rate of 140 beats per minute indicates severe tachycardia, a life-threatening complication of thyroid crisis requiring immediate intervention.
Because the client is receiving levothyroxine (Synthroid) for the first time, the nurse recognizes the need to cheese the client to assess the effect of the effect of replacement therapy. For which signs and symptoms should the nurse assess? Select all that apply.
- A. Dyspnea
- B. Palpitations
- C. Excessive bruising
- D. Raised, red rash
- E. Hyperactivity
- F. Insomnia
Correct Answer: B,E,F
Rationale: Levothyroxine can cause signs of hyperthyroidism if overdosed, including palpitations, hyperactivity, and insomnia.
The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting 'funny.' Which intervention should the nurse implement first?
- A. Instruct the UAP to obtain the blood glucose level.
- B. Have the client drink eight (8) ounces of orange juice.
- C. Go to the client's room and assess the client for hypoglycemia.
- D. Prepare to administer one (1) ampule 50% dextrose intravenously.
Correct Answer: C
Rationale: Assessing for hypoglycemia (e.g., confusion, headache) confirms the cause, as Humulin R peaks around 3 hours. UAPs cannot check glucose, and treatment follows confirmation.
The nurse receives orders for the newly admitted client with Addison's disease. Which orders should the nurse question with the HCP? Select all that apply.
- A. Potassium 20 mEq oral now
- B. Sodium-restricted diet of 1000 mg
- C. Serum cortisol level in early am.
- D. Obtain serum glucose level now
- E. 5% dextrose in NS at 100 mL/hr
Correct Answer: A,B
Rationale: Potassium administration and a sodium-restricted diet are inappropriate as Addison's disease causes hyperkalemia and hyponatremia.