a client with diabetes mellitus is scheduled for surgery and their blood glucose level is 280 mgdl what is the nurses priority action
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet Capstone

1. A client with diabetes mellitus is scheduled for surgery, and their blood glucose level is 280 mg/dL. What is the nurse's priority action?

Correct answer: A

Rationale: The correct answer is A: Administer insulin as prescribed. In clients with diabetes, high blood glucose levels can increase the risk of infection and impair healing after surgery. Administering insulin as prescribed helps reduce blood glucose to a safer level before surgery, preventing complications. Choice B is incorrect because delaying surgery without addressing the high blood glucose level does not address the immediate issue. Choice C is incorrect as checking the client's hemoglobin A1C level is not the priority when dealing with acute high blood glucose levels before surgery. Choice D is incorrect as administering IV fluids may help with hydration but does not directly address the high blood glucose level that needs immediate attention.

2. What might be suggested to a client with fibrocystic breasts in an attempt to help relieve symptoms?

Correct answer: B

Rationale: The correct answer is B: 'Wear a supportive bra during the day and at night.' Wearing a supportive bra is essential for individuals with fibrocystic breasts as it helps relieve discomfort by providing necessary support to reduce strain on breast tissue. Option A is incorrect as high-calcium foods are not directly related to symptom relief in fibrocystic breasts. Option C is not the first-line recommendation and may not address the underlying issue. Option D, performing regular breast massage, is not typically recommended and may not provide significant relief for fibrocystic breast symptoms.

3. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?

Correct answer: B

Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene is important to prevent complications.

4. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication ____________.

Correct answer: A

Rationale: The correct answer is A: Can predispose to dysrhythmias. Hypokalemia combined with digoxin increases the risk of dysrhythmias due to the potentiation of digoxin's effects on cardiac conduction. Choice B, May lead to oliguria, is incorrect because hypokalemia is not typically associated with oliguria. Choice C, May cause irritability and anxiety, is incorrect as these symptoms are more commonly associated with hypocalcemia. Choice D, Sometimes alters consciousness, is incorrect as altered consciousness is not a typical effect of hypokalemia combined with digoxin.

5. A client with diabetes mellitus is admitted with an infected foot ulcer. What intervention is most important for the nurse to implement?

Correct answer: B

Rationale: Administering prescribed IV antibiotics is the most crucial intervention in managing an infected foot ulcer in a client with diabetes mellitus. Antibiotics help combat the infection and prevent its spread systemically, which is vital in diabetic clients to prevent serious complications like sepsis. While obtaining a wound culture (Choice A) may provide valuable information for targeted antibiotic therapy, administering antibiotics promptly takes precedence to prevent the infection from worsening. Elevating the affected foot (Choice C) can help reduce swelling but is not as urgent as administering antibiotics. Consulting the wound care nurse (Choice D) may be beneficial for long-term wound management but does not address the immediate need to control the infection.

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