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A client who has type 2 diabetes mellitus takes metformin 500 mg PO daily for blood glucose control. The client has been NPO since midnight in preparation for general anesthesia and surgery. At 0700 the client's serum glucose level is 250 mg/dL (13.9 mmol/L). Which action should the nurse implement?
Reference Range :Fasting Blood Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Obtain a prescription for regular insulin SUBQ per sliding scale.

Record the blood glucose results and requisition a repeat test in one hour.

Prepare to initiate a continuous IV infusion of Insulin in normal saline.

Administer the client's daily metformin tablet with a sip of water.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Administering insulin per sliding scale is appropriate for managing elevated blood glucose in a patient who is NPO and cannot take oral hypoglycemics like metformin.

B. Repeating the test in one hour delays necessary treatment and does not address the current hyperglycemia.

C. A continuous IV infusion of insulin is more appropriate for severe hyperglycemia or critical care situations, but obtaining a sliding scale prescription is more routine in this context.

D. Administering metformin with a sip of water could be considered if the provider orders it, but typically, oral hypoglycemics are held when a patient is NPO.

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A. Use a pulse oximeter to assess oxygen saturation. B. Advise the client to reduce the medication dose. C. Report the finding to the healthcare provider. D. Check the client's capillary glucose level.

Correct Answer is C

Explanation

Rationale:

A. Jaundice is not related to oxygen saturation, so using a pulse oximeter is not appropriate in this situation.

B. Reducing the dose of acetaminophen may be necessary, but this decision should be made after evaluating liver function.

C. Jaundice, characterized by yellowing of the skin, can indicate liver dysfunction, possibly due to acetaminophen overuse or toxicity. The nurse should report this finding to the healthcare provider immediately for further evaluation and management.

D. Checking capillary glucose levels is not relevant to the assessment of jaundice.

A. Turn the overhead lights on while giving instructions. B. Stand behind the client to avoid intimidation. C. Provide handouts written at a 12th grade reading level. D. Use background music to promote relaxation.

Correct Answer is A

Explanation

Rationale:

A. Turning on overhead lights ensures that the client can see the instructions clearly, which is particularly important for older adults who may have visual impairments. Adequate lighting helps improve comprehension and reduces the risk of misunderstandings.

B. Standing behind the client may cause confusion or discomfort. It is better to face the client while communicating.

C. Handouts should be written at a lower reading level, typically around the 5th to 6th grade, to ensure that most clients can understand them, especially older adults.

D. Background music may be distracting rather than helpful during the provision of important instructions.

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Correct Answer is C

Explanation

An older client is admitted to the medical-surgical unit after falling and fracturing the left hip. The nurse is reviewing written preoperative instructions with the client and spouse. Which action should the nurse implement while providing these instructions?

Correct Answer is A

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