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Two hours after taking a regular morning dose of regular insulin, the client presents to a clinic with diaphoresis, tremors, palpitations, and tachycardia. Which nursing action is most appropriate?
- A. Check pulse oximetry; if 94% or less, start oxygen at 2 L per nasal cannula.
- B. Give a baby aspirin and one nitroglycerin tablet; obtain an electrocardiogram.
- C. Check blood glucose level; provide carbohydrates if less than 70 mg/dL (3.8 mmol/L).
- D. Check heart rate; if the HR is above 120 beats per minute, give atenolol 25 mg orally.
Correct Answer: C
Rationale: Regular insulin peaks in 2 to 4 hours after administration. The client's symptoms suggest hypoglycemia, so a blood glucose level should be checked and carbohydrates given if low.
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Which action is the best indication that the client needs more practice in combining two insulins in one syringe?
- A. The client rolls the vial of intermediate-acting insulin to mix it with its additive.
- B. The client still have a little or less the fast-acting and intermediate-acting insulin vials.
- C. The client instills the intermediate-acting insulin into the vial of rapid-acting insulin.
- D. The client inverts each vial before withdrawing the specified amount of insulin.
Correct Answer: C
Rationale: Instilling insulin into another vial contaminates the medication and is incorrect.
The nurse writes a problem of 'altered body image' for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented?
- A. Monitor blood glucose levels prior to meals and at bedtime.
- B. Perform a head-to-toe assessment on the client every shift.
- C. Use therapeutic communication to allow the client to discuss feelings.
- D. Assess bowel sounds and temperature every four (4) hours.
Correct Answer: C
Rationale: Therapeutic communication addresses body image concerns (e.g., moon face, weight gain) in Cushing’s, promoting coping. Glucose, assessments, and bowel sounds are unrelated.
The client admitted to rule out pancreatic islet tumors complains of feeling weak, shaky, and sweaty. Which priority intervention should be implemented by the nurse?
- A. Start an IV with D5W.
- B. Notify the health-care provider.
- C. Perform a bedside glucose check.
- D. Give the client some orange juice.
Correct Answer: C
Rationale: Weakness, shakiness, and sweating suggest hypoglycemia from an insulinoma; a glucose check confirms this, guiding treatment. IV D5W, HCP notification, and juice follow confirmation.
The nurse is caring for the client with elevated growth hormone (GH) levels. Which problem should the nurse exclude from the plan of care?
- A. Fluid volume deficit due to polyuria
- B. Insomnia due to soft tissue swelling
- C. Impaired communication due to speech difficulties
- D. Altered body image due to undersized hands, feet, and jaw
Correct Answer: D
Rationale: GH excess causes overgrowth of bones and soft tissues, not undersizing, so altered body image due to undersized features is excluded.
The nurse is caring for clients on a medical floor. Which client should be assessed first?
- A. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday.
- B. The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours.
- C. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching.
- D. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night.
Correct Answer: C
Rationale: Muscle twitching in SIADH suggests hyponatremia-induced neurological symptoms, requiring immediate assessment. Weight gain, slight DI output imbalance, and tiredness are less urgent.