Nokea
The nurse is planning to complete noon assessments for four assigned clients with type 1 DM. All of the clients received subcutaneous insulin aspart at 0800 hours. Place the clients in the order of priority for the nurse's assessment.
- A. The 60-year-old client who is nauseated and has just vomited for the second time
- B. The 45-year-old client who is dyspneic and has chest pressure and new-onset atrial fibrillation
- C. The 75-year-old client with a fingerstick blood glucose level of 300 mg/dL
- D. The 50-year-old client with a fingerstick blood glucose level of 70 mg/dL
Correct Answer: B,A,C,D
Rationale: The 45-year-old client with dyspnea, chest pressure, and atrial fibrillation is at risk for a cardiac event, requiring immediate assessment. The 60-year-old with vomiting is next due to potential hypoglycemia. The 75-year-old with hyperglycemia needs attention but is less urgent. The 50-year-old with normal glucose is last.
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The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse?
- A. Serum blood glucose level of 74 mg/dL.
- B. Pulse oximeter reading of 90%.
- C. Telemetry reading showing sinus bradycardia.
- D. The client is lethargic and sleeps all the time.
Correct Answer: B
Rationale: A pulse oximetry of 90% indicates hypoxia, requiring immediate intervention in myxedema coma. Normal glucose, bradycardia, and lethargy are expected.
Which information is most important for the nurse to elicit from the client to effectively evaluate compliance with the prescribed therapy?
- A. The dosage and frequency of insulin administration
- B. The client's glucose monitoring records for the past week
- C. The client's weight and vital signs before the office interview
- D. The symptoms experienced in the past month
Correct Answer: B
Rationale: Glucose monitoring records provide direct evidence of blood glucose control and therapy compliance.
Based on the client's blood glucose measurement, the nurse immediately reevaluates the client. Which physician orders should the nurse anticipate? Select all that apply.
- A. STAT serum blood glucose
- B. Intravenous regular insulin
- C. Vital signs every 2 hours
- D. A diet of six small, frequent meals
- E. Electronic glucometer measurements before meals and at bedtime
- F. Continuous cardiac monitoring
Correct Answer: A,B,E,F
Rationale: DKA with a glucose of 498 mg/dL requires STAT serum glucose, IV insulin, frequent glucometer checks, and cardiac monitoring.
The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrant immediate intervention?
- A. The client is alert to name but is unable to tell the nurse the location.
- B. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL.
- C. The client's vital signs are T 97.6°F, P 88, R 20, and BP 130/80.
- D. The client has a 3-cm amount of dark-red drainage on the turban dressing.
Correct Answer: B
Rationale: High output (2,500 mL vs. 1,000 mL intake) suggests diabetes insipidus, requiring immediate intervention to prevent dehydration. Disorientation, normal vitals, and drainage are less urgent.
The nurse reviews the HCP's orders for the newly admitted client diagnosed with DKA. Which order should the nurse question?
- A. Administer D5W intravenously (IV) at 125 mL per hour
- B. Administer KCL 10 mEq in 100 mL NaCl IV now
- C. Give sodium bicarbonate IV per pharmacy dosing if arterial pH is less than 7.0
- D. Start regular insulin infusion per protocol; titrate based on hourly glucose level
Correct Answer: A
Rationale: In DKA, the blood glucose level is above 300 mg/dL. Additional glucose will increase the glucose level further. Initially 0.45% or 0.9% sodium chloride (NaCl) is administered for fluid resuscitation.