ADN 120 Exam 1
A client with type 2 diabetes, who is taking an oral hypoglycemic agent, is to have a serum glucose test early in the morning. The client asks the nurse, "What do I have to do to prepare for this test?" Which statement by the nurse reflects accurate information? "Eat your usual breakfast." "Have clear liquids for breakfast." "Take your medication before the test." "Do not ingest anything before the test."
"Do not ingest anything before the test." Fasting before the test is indicated for accurate and reliable results; food before the test will increase serum glucose levels through metabolism of the nutrients. Food should not be ingested before the test; food will increase the serum glucose level, negating accuracy of the test. Instructing the client to have clear liquids for breakfast is inappropriate; some clear fluids contain simple carbohydrates, which will increase the serum glucose level. Medications are withheld before the test because of their influence on the serum glucose level.
An older adult with chills arrived to hospital. The nurse assesses the client's vital signs and determined the client has a fever. What would be the client's rectal temperature? 36.0ºC 36.8ºC 37.2ºC 38.5ºC
38.5ºC (In older adults the normal temperature range is 36° to 36.8°C orally and 36.6° to 37.2°C rectally. In febrile conditions, the rectal temperature would be more than 37.5°C. A rectal temperature of 38.5°C would indicate a fever.)
A 10-year-old girl with diabetes joins the school's soccer team. Her mother is unsure whether to tell the coach of her child's condition. The mother asks the school nurse for guidance. On what information should the nurse base the response? Children with diabetes who participate in active sports can have episodes of hypoglycemia. Children may have to leave athletic teams if school authorities learn that they have diabetes. The school nurse will treat the child if clinical findings of hypoglycemia are recognized early. The coach might violate confidentiality by discussing the child's condition with other faculty members.
Children with diabetes who participate in active sports can have episodes of hypoglycemia. (The people associated with the school who are interacting with the child should be told about the child's condition. Knowledgeable people can be alert for early signs of hypoglycemia and have snacks available for the child to help prevent a hypoglycemic episode. Forcing the child to leave the team is a form of discrimination; children with diabetes are allowed to engage in activities as long as their diabetes remains under control. The adult who is with the child when the signs of hypoglycemia first appear should be prepared to treat the child; this person may or may not be the nurse. Information about the child's health status is on a "need to know" basis; professionals are expected to honor confidentiality.)
A client with type 2 diabetes is taking one oral hypoglycemic tablet daily. The client asks whether an extra tablet should be taken before exercise. What is the best response by the nurse? "You will need to decrease your exercise." "An extra tablet will help your body use glucose correctly." "When taking medicine, your diet will not be affected by exercise." "No, but you should observe for signs of hypoglycemia while exercising."
"No, but you should observe for signs of hypoglycemia while exercising." (Exercise improves glucose metabolism; with exercise there is a risk of developing hypoglycemia, not hyperglycemia. Exercise should not be decreased because it improves glucose metabolism. An extra tablet probably will result in hypoglycemia because exercise alone improves glucose metabolism. Control of glucose metabolism is achieved through a balance of diet, exercise, and pharmacologic therapy.)
A nurse is monitoring a client's laboratory results for a fasting plasma glucose level. Within which range of a fasting plasma glucose level does the nurse conclude that a client is considered to be diabetic? 40 to 60 mg/dL (2.2 to 3.3 mmol/L) 80 to 99 mg/dL (4.5 to 5.5 mmol/L) 100 to 125 mg/dL (5.6 to 6.9 mmol/L) 126 to 140 mg/dL (7.0 to 7.8 mmol/L)
126 to 140 mg/dL (7.0 to 7.8 mmol/L) (Results in the range 126 to 140 mg/dL (7.0 to 7.8 mmol/L) indicate diabetes. Results in the range 40 to 60 mg/dL (2.2 to 3.3 mmol/L) indicate hypoglycemia. Results in the range 80 to 99 mg/dL (4.5 to 5.5 mmol/L) are considered expected (normal). Results in the range 100 to 125 mg/dL (5.6 to 6.9 mmol/L) indicate prediabetes according to the American Diabetes Association. (Results in the range of 6.1 to 6.9 mmol/L indicate prediabetes according to the Canadian Diabetes Association Guidelines.)
After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature? A fever may lead to diaphoresis. A fever increases the cardiac output. An increased temperature indicates cerebral edema. An increased temperature may be a sign of hemorrhage.
A fever increases the cardiac output. (Temperatures of 102° F (38.9° C) or greater lead to an increased metabolism and cardiac workload. Although diaphoresis is related to an elevated temperature, it is not the reason for notifying the healthcare provider. An elevated temperature is not an early sign of cerebral edema. Open heart surgery is not associated with cerebral edema. Fever is unrelated to hemorrhage; in hemorrhage with shock, the temperature decreases.)
A client is receiving total parenteral nutrition. The nurse assesses for which client response that indicates hyperglycemia? Paralytic ileus Respiratory rate below 16 A fruity odor to the breath Serum glucose of 105 mg/100 mL
A fruity odor to the breath (Hyperglycemia is indicated by a fruity odor to the breath. Paralytic ileus is not associated with hyperglycemia. With hyperglycemia there is hyperventilation. Serum glucose of 105 mg/100 mL is within the expected range.)
A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F (39° C). The temperature was 99.2° F (37.3° C) when it was taken 6 hours ago. What is a priority nursing intervention in this case? Assess the amount and color of urine; obtain a specimen for a urinalysis. Administer the prescribed antipyretic and notify the primary health care provider. Note the consistency of respiratory secretions and obtain a specimen for culture. Obtain the respirations, pulse, and blood pressure; recheck the temperature in 1 hour
Administer the prescribed antipyretic and notify the primary health care provider. (Because an elevated temperature increases metabolic demands, the pyrexia must be treated immediately. The practitioner should be notified because this client is immunodeficient from both the disease and the chemotherapy. A search for the cause of the pyrexia then can be initiated. More vigorous intervention than obtaining the respirations, pulse, and blood pressure is rechecking the temperature in 1 hour. This client has a disease in which the immunoglobulins are ineffective and the therapy further suppresses the immune system. Assessing the amount and color of urine and obtaining a specimen for a urinalysis is not the immediate priority, although it is important because the cause of the pyrexia must be determined. Also, the increased amount of calcium and urates in the urine can cause renal complications if dehydration occurs. Noting the consistency of respiratory secretions and obtaining a specimen for culture is not the priority, although important because respiratory tract infections are a common occurrence in clients with multiple myeloma.Test-Taking Tip: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will help keep you calm and give you energy.)
A nurse explains to a client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing. Why is blood glucose monitoring preferred? Blood glucose monitoring is more accurate. Blood glucose monitoring is easier to perform. Blood glucose monitoring is done by the client. Blood glucose monitoring is not influenced by drugs.
Blood glucose monitoring is more accurate (Blood glucose testing is a more direct and accurate measure; urine testing provides an indirect measure that can be influenced by kidney function and the amount of time the urine is retained in the bladder. Whereas blood and urine testing is relatively simple, testing the blood involves additional knowledge. Both procedures can be done by the client. Whether or not it is influenced by drugs is not a factor. Although some urine tests are influenced by drugs, there are methods to test urine to bypass this effect.)
A nurse is planning care for a toddler who has ingested aspirin. What assessment warrants close monitoring because an increase can result in further complications? Blood pressure Abdominal girth Body temperature Serum glucose level
Body temperature (Hyperpyrexia (increased temperature) is a manifestation of acute aspirin poisoning; this leads to increased oxygen consumption and heat loss. Blood pressure is not directly affected by aspirin ingestion. Ascites does not occur as a result of aspirin ingestion; it may occur if liver failure develops. Aspirin ingestion does not affect the serum glucose level.)
A primary healthcare provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated. Which principle does the nurse determine is in operation when the application of local heat transfers temperature to the body? Radiation Insulation Convection Conduction
Conduction (Conduction is the conveyance of energy such as heat, cold, or sound by direct contact. Direct contact is not necessary to convey heat by radiation. Insulation refers to retention of heat, not its transfer. Convection is the transfer of heat by air circulation (e.g., by fans or open windows).
A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? Deficient fluid volume Impaired skin integrity Inadequate nutritional intake Decreased participation in activities
Deficient fluid volume (The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid. Although impaired skin integrity is a concern with dehydration, it is not the priority. The rapid weight loss reflects a loss of fluid, not a loss of body tissue. Although the client may need assistance with activities, an inadequate intake of fluid has caused the client's dehydration, which is a serious medical problem that needs to be treated immediately.)
A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include to decrease the risk of complications? Select all that apply. Examine the feet daily Wear well-fitting shoes Perform regular exercise Powder the feet after showering Visit the primary healthcare provider weekly Test bathwater with the toes before bathing
Examine the feet daily Wear well-fitting shoes Perform regular exercise (Clients with diabetes often have peripheral neuropathies and are unaware of discomfort or pain in the feet; the feet should be examined every night for signs of trauma. Well-fitting shoes prevent pressure and rubbing that can cause tissue damage and the development of ulcers. Daily exercise increases the uptake of glucose by the muscles and improves insulin use. Powdering the feet after showering may cause a pastelike residue between the toes that may macerate the skin and promote bacterial and fungal growth. Generally, visiting the primary healthcare provider weekly is unnecessary. Clients with diabetes often have peripheral neuropathy and are unable to accurately evaluate the temperature of bathwater, which can result in burns if the water is too hot.)
The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. Dyspnea Flushed face Precordial pain Increased pulse rate Increased blood pressure
Flushed face Increased pulse rate (Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.)
A school-aged child with type 1 diabetes is admitted to the pediatric unit in ketoacidosis. What sign of ketoacidosis does the nurse expect to identify when assessing the child? Sweating Hyperpnea Bradycardia Hypertension
Hyperpnea (Deep, rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a compensatory mechanism associated with metabolic acidosis. Sweating is a physiological response to hypoglycemia. Tachycardia, not bradycardia, results from the hypovolemia caused by the polyuria associated with ketoacidosis. Hypotension, not hypertension, may result from the decreased vascular volume caused by the polyuria associated with ketoacidosis.)
An unconscious 16-year-old adolescent with type 1 diabetes is brought to the emergency department. The blood glucose level is 742 mg/dL (41.2 mmol/L). What finding does the nurse expect during the initial assessment? Pyrexia Hyperpnea Bradycardia Hypertension
Hyperpnea (Rapid breathing is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a characteristic compensatory mechanism for correcting metabolic acidosis. An increase in temperature will occur if an infection is present; it is not a response to hyperglycemia. Tachycardia, not bradycardia, results from the hypovolemia of dehydration. Hypotension, not hypertension, may result from the decreased vascular volume associated with hyperglycemia.)
A client with type 1 diabetes receives 30 units of NPH insulin at 7 am. At 3:30 pm the client becomes diaphoretic, weak, and pale. What does the nurse determine that these physiologic responses are associated with? Diabetic coma Somogyi effect Diabetic ketoacidosis Hypoglycemic reaction
Hypoglycemic reaction These are sympathetic nervous system responses to hypoglycemia; the peak action of NPH insulin is 8 to 12 hours after administration, and 8.5 hours have elapsed since it was given. The signs and symptoms of diabetic coma are dry mucous membranes; hot, flushed skin; deep, rapid respirations (Kussmaul breathing); acetone odor to the breath; nausea and vomiting; and, as with hypoglycemia, weakness. The Somogyi effect includes wide swings in blood glucose levels between hyperglycemia and a profound hypoglycemia caused by insulin rebound. Ketoacidosis results from excess use of fats for energy when carbohydrates cannot be used. Lipids are metabolized incompletely, and dehydration, acidosis (both ketotic and lactic), and electrolyte imbalance result. It is not the result of insulin administration.
A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition? Pons Medulla Thalamus Hypothalamus
Hypothalamus (The hypothalamus controls the body temperature. Damage to the hypothalamus may cause abnormalities in the body temperature values during a physical assessment. The pons is responsible for maintaining level of consciousness. The medulla controls heart rate and breathing. The thalamus performs motor and sensory functions.)
A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What increased risk does the nurse consider when assessing this client? Weight loss Hypoglycemia Decreased blood pressure Inadequate wound healing
Inadequate wound healing (Because the antiinflammatory response is depressed as a result of increased cortisol levels, the wounds of clients receiving long-term corticosteroid therapy tend to heal slowly. A common finding associated with long-term corticosteroid use is weight gain, caused not only by fluid retention but also by alterations in fat, carbohydrate, and protein metabolism. Persistent hyperglycemia (steroid diabetes) occurs because of altered glucose metabolism. Hypertension, not hypotension, occurs as a result of sodium and fluid retention.)
A client with a history of hypothyroidism reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as heat stroke? Increased heart rate Increased blood pressure Decreased respiratory rate Increased circulatory damage
Increased heart rate (Prolonged exposure to the sun or a high environmental temperature overwhelms the body's heat-loss mechanisms. These conditions cause heat stroke, which manifests as giddiness, excessive thirst, and nausea. An increased heart rate (HR) characterizes a heat stroke. A low blood pressure (BP), increased respiratory rate, and increased circulatory and tissue damage are not indicators of heat stroke.)
A client with type 1 diabetes is transported via ambulance to the emergency department of the hospital. The client has dry, hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? Ketoacidosis Somogyi phenomenon Hypoglycemic reaction Hyperosmolar nonketotic coma
Ketoacidosis (Ketoacidosis occurs when insulin is lacking and carbohydrates cannot be used for energy; this increases the breakdown of protein and fat, causing deep, rapid respirations (Kussmaul respirations), decreased alertness, decreased circulatory volume, metabolic acidosis, and an acetone breath. The Somogyi phenomenon is a rebound hyperglycemia induced by severe hypoglycemia; there are not enough data to determine whether this occurred. Hypoglycemia is manifested by cool, moist skin, not hot, dry skin; Kussmaul respirations do not occur with hypoglycemia. Hyperosmolar nonketotic coma usually occurs in clients with type 2 diabetes because available insulin prevents the breakdown of fat.)
The nurse provides education about signs and symptoms of hypoglycemia to a client with newly diagnosed type 1 diabetes. The nurse concludes that the teaching was effective when the client acknowledges the need to drink orange juice when experiencing which symptoms? Nervous and weak Thirsty with a headache Flushed and short of breath Nausea and abdominal cramps
Nervous and weak (Nervousness and weakness are the most commonly reported symptoms of hypoglycemia and are related to increased sympathetic nervous system activity. Feeling flushed and short of breath are adaptations of hyperglycemia. Being thirsty, having a headache, being nauseated, or having abdominal cramps are symptoms of hyperglycemia.)
An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? Select all that apply. Massage extremities. Obtain a rectal temperature. Assess the fingers for areas of frostbite. Determine client's level of consciousness. Ask for client identification.
Obtain a rectal temperature. Assess the fingers for areas of frostbite. Determine client's level of consciousness. Ask for client identification. (A rectal temperature provides the most accurate temperature. Older adults have less subcutaneous fat and inefficient temperature-regulating mechanisms, which makes them vulnerable to extremes in environmental temperature. The extremities are more distal sites of circulation and are at increased risk for frostbite. Hypothermia decreases cerebral perfusion, which will result in confusion and a decreased level of consciousness. Getting client identification will help in learning more about the client's previous health history and aid in contacting family members. Massage is contraindicated because it may injure tissues that have sustained frostbite)
A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply. Oral temperature of 98.2° F (36.8° C) Apical pulse of 88 beats per minute and regular Respiratory rate of 30 per minute Blood pressure of 116/78 mm Hg while in a sitting position Oxygen saturation of 92%
Oral temperature of 98.2° F (36.8° C) Apical pulse of 88 beats per minute and regular Blood pressure of 116/78 mm Hg while in a sitting position (The client's temperature, pulse, and blood pressure are within normal ranges for a 50-year-old female. The client's respirations are mildly elevated, and the oxygen saturation level is below normal. A normal respiratory rate for a female client in this age group would be 12 to 20 per minute, and oxygen saturation level should be 95%.)
A 7-year-old child who has sustained frostbite of the toes after skiing in below-freezing weather is brought to the emergency department. What is the nurse's initial intervention? Rapidly rewarming the toes by placing the feet in warm water Slowly rewarming the toes by wrapping the feet in a warm cloth Placing the feet in cool water to minimize the temperature difference Wrapping the feet in an ice pack until definitive medical help is available
Rapidly rewarming the toes by placing the feet in warm water (Rapid rewarming is accomplished by immersing the body part in well-agitated water at 100° F to 108° F (37.8° C to 42.2° C). Rapid rewarming minimizes tissue damage. The body part should be rewarmed as quickly as possible to minimize tissue damage. Prolonged exposure to the cold will worsen tissue damage.)
The nurse finds that the client's fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of? Relapsing Sustained Remittent Intermittent
Remittent (In a remittent pattern, fever spikes and falls without returning to normal temperature levels. Periods of febrile episodes coupled with periods of acceptable temperature values are called a relapsing pattern. A constant body temperature continuously above 38° C (100.4° F) with little fluctuation refers to a sustained pattern. In an intermittent pattern, fever spikes are interspersed with normal temperature levels.)
On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action? Covering the infant with a bath blanket Sponging the infant with tepid alcohol Removing excess clothing from the infant Reassessing the infant's temperature in several hours
Removing excess clothing from the infant (After the initial safety measures and notification of the practitioner have been addressed, excess clothing, which prevents heat loss, should be removed. Covering the infant will increase the temperature because heat loss will be reduced. Alcohol should never be used for infants or children; it causes severe chilling, which can lead to increased metabolic activity and a higher temperature. This high fever requires more frequent readings, usually at least every hour. )
A nurse working in the diabetes clinic is evaluating a client's success with managing the medical regimen. What is the best indication that a client with type 1 diabetes is successfully managing the disease? Reduction in excess body weight Stabilization of the serum glucose Demonstrated knowledge of the disease Adherence to the prescription for insulin
Stabilization of the serum glucose (A combination of diet, exercise, and medication is necessary to control the disease; the interaction of these therapies is reflected by the serum glucose level. Weight loss may occur with inadequate insulin. Acquisition of knowledge does not guarantee its application. Insulin alone is not enough to control the disease.)
A nurse is teaching a client with type 1 diabetes about assessing for signs and symptoms of hypoglycemia as a result of excessive insulin. What response should the nurse instruct the client to monitor in addition to nervousness and hunger? Thirst Nausea Anorexia Sweating
Sweating (When serum glucose decreases, the sympathetic nervous system is stimulated, resulting in a surge of epinephrine and norepinephrine; this response causes sweating, tremors, tachycardia, palpitations, nervousness, and hunger. Increased thirst (polydipsia) occurs in response to the osmotic diuresis associated with hyperglycemia. The ketosis and acidosis of diabetic ketoacidosis lead to gastrointestinal problems such as nausea, anorexia, vomiting, and abdominal cramping.)
A client newly diagnosed with type 1 diabetes is taught to exercise on a regular basis. What is the primary reason for instruction on exercise? To decrease insulin sensitivity To stimulate glucagon production To improve the cellular uptake of glucose To reduce metabolic requirements for glucose
To improve the cellular uptake of glucose (Exercise increases the metabolic rate, and glucose is needed for cellular metabolism; therefore, excess glucose is consumed during exercise. Regular vigorous exercise increases cell sensitivity to insulin. Glucagon action raises blood glucose but does not affect cell uptake or use of glucose. Cellular requirements for glucose increase with exercise.)
When assessing the laboratory values of a client with type 2 diabetes, what would the nurse expect the results to reveal? Ketones in the blood but not in the urine Glucose in the urine but not in the blood Urine and blood positive for glucose and ketones Urine negative for ketones and glucose in the blood The reason for the lack of ketonuria in type 2 diabetes is unknown. One theory is that extremely high hyperglycemia and hyperosmolarity levels block the formation of ketones, stimulating lipogenesis rather than lipolysis. Ketones in the blood but not in the urine do not occur with type 2 diabetes. Glucose in the urine but not in the blood is impossible; if glycosuria is present, there must first be a level of glucose in the blood exceeding the renal threshold of 160 to 180 mg/dL (8.9 to 10 mmol/L). Urine and blood positive for glucose and ketones are expected in type 1 diabetes.
Urine negative for ketones and glucose in the blood The reason for the lack of ketonuria in type 2 diabetes is unknown. One theory is that extremely high hyperglycemia and hyperosmolarity levels block the formation of ketones, stimulating lipogenesis rather than lipolysis. Ketones in the blood but not in the urine do not occur with type 2 diabetes. Glucose in the urine but not in the blood is impossible; if glycosuria is present, there must first be a level of glucose in the blood exceeding the renal threshold of 160 to 180 mg/dL (8.9 to 10 mmol/L). Urine and blood positive for glucose and ketones are expected in type 1 diabetes.
The clinical findings of a client with diabetes mellitus show decreased glucose tolerance. Which complication is anticipated in the client? Cystitis Thin and dry skin Decreased bone density Frequent yeast infections Decreased glucose tolerance may cause frequent yeast infections, but it is not associated with the risk of cystitis, thin and dry skin, and decreased bone density. The risk of cystitis, thin and dry skin, and decreased bone density are due to decreased ovarian production of estrogen
Frequent yeast infections (Decreased glucose tolerance may cause frequent yeast infections, but it is not associated with the risk of cystitis, thin and dry skin, and decreased bone density. The risk of cystitis, thin and dry skin, and decreased bone density are due to decreased ovarian production of estrogen)
While a nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." Which food should the nurse suggest to substitute for broccoli? Peas Corn Green beans Mashed potato
Green beans (According to exchange lists for meal planning, green beans and broccoli are equivalent vegetable substitutes. Peas are a starch and are not an equivalent vegetable substitute for broccoli. Corn is a starch and is not an equivalent vegetable substitute for broccoli. Mashed potato is a starch and is not an equivalent vegetable substitute for broccoli.)
A parent tells the nurse in the emergency department, "My 3-year-old has had a fever for several days and has been vomiting." After prescribed measures to reduce the fever have been instituted, what nursing action is most important? Preventing shivering Restricting oral fluids Measuring output hourly Taking vital signs hourly
Preventing shivering (Shivering increases the metabolic rate, which intensifies the body's need for oxygen and increases body temperature. Restriction of fluids is contraindicated because of the risk for dehydration; fluids should be offered. Although monitoring the child's output will provide information about the level of hydration, it is more important to take action to prevent worsening of the fever. Although monitoring of vital signs is important, it is not the priority.)
What should a nurse teach the client to do to avoid lipodystrophy when self-administering insulin therapy? Exercise regularly. Rotate injection sites. Use the Z-track technique. Avoid massaging the injection site.
Rotate injection sites (Fibrous scar tissue can result from the trauma of repeated injections at the same site. Exercise is unrelated to lipodystrophy, but it reduces blood glucose, which decreases insulin requirements. Insulin is given subcutaneously; the Z-track technique is used with some intramuscular injections. Gentle pressure over the injection site after insulin administration promotes absorption.)
The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother is by performing a heel stick blood test on the newborn. What specifically does this test determine? Blood acidity Glucose tolerance Serum glucose level Glycosylated hemoglobin level
Serum glucose level (Obtaining a blood glucose level is a simple, cost-effective method of testing newborns for suspected hypoglycemia. Although the acidity of the blood will indicate whether the newborn has metabolic acidosis as a result of hypoglycemia, it is more important to determine whether the newborn has hypoglycemia so it can be corrected before acidosis develops. The glucose tolerance test and glycosylated hemoglobin level test are not used in newborns.)
A nurse observes that a client's urine has a sweet fruity odor. Which information is most important to evaluate when performing a further client assessment? Vital signs Fluid balance Serum glucose level Dietary calorie count
Serum glucose level (Sweet fruity-smelling urine is an indicator of ketoacidosis, which can result from uncontrolled diabetes. Hyperglycemia and hypoglycemia are assessed by serum glucose monitoring. Vital signs, fluid imbalance, and dietary counts have no relation to sweet fruity-smelling urine.)
A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. What should the nurse advise the client? Select all that apply. Avoid solid food. Take the oral medication. Drink fluids throughout the day. Monitor capillary glucose levels. Do not take medication until tolerating food Physiologic stress increases gluconeogenesis, requiring continued pharmacologic therapy despite an inability to eat; fluids prevent dehydration; monitoring of glucose levels permits early intervention if necessary. Skipping the oral hypoglycemic agent may precipitate hyperglycemia. Food intake should be attempted to prevent acidosis. Delaying an oral hypoglycemic agent may precipitate hyperglycemia
Take the oral medication. Drink fluids throughout the day. Monitor capillary glucose levels. (Physiologic stress increases gluconeogenesis, requiring continued pharmacologic therapy despite an inability to eat; fluids prevent dehydration; monitoring of glucose levels permits early intervention if necessary. Skipping the oral hypoglycemic agent may precipitate hyperglycemia. Food intake should be attempted to prevent acidosis. Delaying an oral hypoglycemic agent may precipitate hyperglycemia)
A registered nurse instructed the nursing assistive personnel (NAP) to measure the temperature of a client who reports chills and coldness. The nurse believes that the reading is inaccurate. What observations may have led to this conclusion? Select all that apply. The client has a habit of breathing through his or her mouth. The client smoked 40 minutes after his or her temperature was taken. The client ingested juice 30 minutes before his or her temperature was taken. The client ingested food 20 minutes after having his or her temperature was taken. The client ingested medications 10 minutes after having his or her temperature was taken.
The client has a habit of breathing through his or her mouth. The client ingested juice 30 minutes before his or her temperature was taken. (Habitual mouth breathing may result in inaccurate temperature readings. A client who ingested any fluids or food orally or smoke should wait for 20 to 30 minutes his or her temperature was taken. Smoking, ingesting foods, or ingesting mediations after a temperature measurement will not give any false readings.)
