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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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The client diagnosed with diabetes complains of a curtain being drawn across the eyes. Which should the nurse implement first?
- A. Assess the eyes using an ophthalmoscope.
- B. Tell the client to keep the eyes closed.
- C. Notify the health-care provider (HCP).
- D. Call the Rapid Response Team (RRT).
Correct Answer: C
Rationale: A curtain-like vision loss suggests retinal detachment, a diabetic complication requiring urgent HCP notification. Ophthalmoscopy, closing eyes, or RRT are inappropriate first steps.
A friend brings the older adult homeless client to a free health screening clinic. The friend is unable to continue administering the client's morning and evening insulin dose for treating type 1 DM. When advocating for this client, which action by the nurse is most appropriate?
- A. Notify Adult Protective Services about the client's condition and living situation.
- B. Ask where the client lives and whether someone else could administer the insulin.
- C. Arrange with a local homeless shelter to have someone give the insulin injections.
- D. Have the client return to the screening clinic morning and evening to receive the injections.
Correct Answer: C
Rationale: The nurse advocates by ensuring that the client has access to health care services. The nurse should contact a social worker whose role it is to make placement arrangements.
An 18-year-old female client, 5'4 tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two (2) weeks. Which disease process should the nurse suspect the client has developed?
- A. Type 1 diabetes.
- B. Type 2 diabetes.
- C. Gestational diabetes.
- D. Acanthosis nigricans.
Correct Answer: B
Rationale: Obesity (BMI ~44) and a nonhealing wound suggest type 2 diabetes, associated with insulin resistance. Type 1 is less likely, gestational diabetes requires pregnancy, and acanthosis nigricans is a symptom, not a disease.
A client has a transsphenoidal hypophysectomy to remove a pituitary tumor. When the client returns to the nursing unit following surgery, the head of the bed is elevated 30 degrees. What is the primary purpose for placing the client in this position?
- A. To promote respiratory effort
- B. To reduce pressure on the sella turcica
- C. To prevent acidosis
- D. To promote oxygenation
Correct Answer: B
Rationale: Elevating the head 30 degrees reduces pressure on the sella turcica, minimizing the risk of cerebrospinal fluid leakage post-hypophysectomy.
Which documentation finding provides the best indication that the client has successfully avoided an adrenal (addisonian) crisis after surgery?
- A. The client's pedal edema has lessened.
- B. Capillary blood glucose level is within normal limits.
- C. Vital signs are within preoperative ranges.
Correct Answer: C
Rationale: Stable vital signs indicate the absence of adrenal crisis, characterized by hypotension and shock.