Difficulty: Medium
Average Score: 92%
Simulated
Passage / Scenario
A nurse is caring for a client who has diabetes mellitus, type 1 Day 3 of hospital0700
Temperature 37.3┬░C (981) Boot
Heart rate 121
118/62 mm Hg Temperature 30.8┬░
Be pressure 104mm Hg 0730
Fingerstick blood glucose, fasting 110 mg/dl. (74 to 106 mg/dL) NPH insulin 40 units subcutaneous administered into abdomen
0830
Client reports nausea with emesis: vomited morning meal 1130
Client reports feeling shaky, hungry, skin cool and diaphoretic Fingerstick blood glucose 55 mg/dL
HbA1c 8.01% (less than 7% greater than 129%)
Select the findings that require immediate follow up
Correct answer
A,B,E
Rationale
Low glucose (55 mg/dL), shakiness, and elevated heart rate (121) indicate hypoglycemia requiring immediate intervention.