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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. Remove the drainage bag and apply antibiotic ointment around the stoma. B. Apply a pulse oximeter to determine the client's oxygen saturation level. C. Replace the colostomy supplies with non-latex hypoallergenic supplies. D. Notify the healthcare provider of the appearance of the stoma immediately.

Correct Answer is D

Explanation

Rationale:

A. Applying antibiotic ointment is not appropriate for this situation as the issue is likely compromised blood flow, not infection.

B. Checking oxygen saturation is not related to the color change of the stoma.

C. Switching to non-latex supplies is important for clients with latex allergies but is not relevant to the immediate problem.

D. A dark red to bluish color of the stoma suggests compromised blood flow and possible ischemia, which requires immediate medical attention. The nurse should notify the healthcare provider immediately to address this potentially serious complication.

A. Discuss with the client that there may be a need for additional sleep if the feeling of fatigue is present the next day. B. Encourage the client to obtain a prescription for a benzodiazepine antagonist. C. Instruct the client that it is important to reduce the dose of the medication gradually. D. Advise the client to stop taking the medication immediately.

Correct Answer is C

Explanation

Rationale:

A. While additional sleep may be helpful, it does not address the root cause of the hangover effect from temazepam.

B. A benzodiazepine antagonist is typically used in cases of overdose, not for managing next-day drowsiness.

C. Temazepam is a benzodiazepine, and sudden discontinuation can lead to withdrawal symptoms. The nurse should advise the client to taper off the medication gradually under medical supervision to prevent withdrawal symptoms and minimize the "hangover" effect.

D. Stopping the medication abruptly can lead to withdrawal symptoms and is not recommended.

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

Correct Answer is D

Explanation

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

Correct Answer is C

Explanation

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