At 4:45 p.m., a nurse assesses a client with diabetes mellitus ...

[nummyann]

At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below:
 
  Capillary Blood Glucose Testing (AC/HS)
  Dietary
  Intake
  At 0630: 95
  At 1130: 70
  At 1630: 47
  Breakfast: 10 eaten - client states she is not hungry
  Lunch: 5 eaten - client is nauseous; vomits once
  After reviewing the client's assessment data, which action is appropriate at this time?
  a.
  Assess the client's oxygen saturation level and administer oxygen.
  b.
  Reorient the client and apply a cool washcloth to the client's forehead.
  c.
  Administer dextrose 50 intravenously and reassess the client.
  d.
  Provide a glass of orange juice and encourage the client to eat dinner.

Question 2

A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this client's teaching? (Select all that apply.)
 
  a. Do not walk around barefoot.
  b. Soak your feet in a tub each evening.
  c. Trim toenails straight across with a nail clipper.
  d. Treat any blisters or sores with Epsom salts.
  e. Wash your feet every other day.

[TheNamesImani]

Answer to Question 1

ANS: C
The client's symptoms are related to hypoglycemia. Since the client has not been tolerating food, the nurse should administer dextrose intravenously. The client's oxygen level could be checked, but based on the information provided, this is not the priority. The client will not be reoriented until the glucose level rises.

Answer to Question 2

ANS: A, C
Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client should be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client should be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds.