A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about

Correct Answer: C

Rationale: When a patient has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L), indicating prediabetes, the initial approach is focused on lifestyle modifications to lower blood glucose levels. These changes may include dietary adjustments, increased physical activity, and weight management. Self-monitoring of blood glucose, insulin therapy, and oral hypoglycemic medications are not typically the first-line interventions for patients with prediabetes. Educating the patient about lifestyle changes to lower blood glucose is the most appropriate action at this stage.

Correct Answer: B

Rationale: After a patient treated with intramuscular glucagon for hypoglycemia regains consciousness, providing a snack of peanut butter and crackers is essential to prevent another episode of hypoglycemia. Peanut butter and crackers contain a combination of protein and carbohydrates, which can help stabilize the patient's blood glucose levels. This choice is the most appropriate immediate action to prevent recurrence of hypoglycemia in this scenario. Assessing for symptoms of hyperglycemia (choice A) is not the immediate priority after treating hypoglycemia. While orange juice or nonfat milk (choice C) can help raise blood sugar, they lack the sustained effect of protein found in peanut butter. Administering continuous infusion of dextrose (choice D) is excessive and not indicated after the patient has already regained consciousness.

Correct Answer: C

Rationale: The correct action for the nurse to take first when a patient reports feeling lightheaded and sweaty after being weaned off an insulin drip is to obtain a glucose reading using a finger stick. This will provide crucial information on the patient's current blood glucose level, helping the nurse assess if the symptoms are due to hypoglycemia. Based on the glucose reading, appropriate interventions can be initiated, such as administering dextrose, glucagon, or oral sugars like orange juice if hypoglycemia is confirmed. However, verifying the blood glucose level is the initial step to guide subsequent actions and ensure patient safety.

Correct Answer: B

Rationale: The patient with a blood glucose level of 40 mg/dL (hypoglycemia) needs immediate attention as it is an emergency situation that requires prompt intervention to prevent adverse effects. Severe hypoglycemia can lead to serious complications, such as seizures or loss of consciousness. Therefore, the nurse should prioritize assessing and managing this patient first to prevent further deterioration. Choices A, C, and D do not present immediate life-threatening situations requiring urgent intervention like severe hypoglycemia does. A high hemoglobin A1C level, an abnormal oral glucose tolerance test result, and acute abdominal pain, while important, do not pose an immediate threat to the patient's life compared to severe hypoglycemia.

Correct Answer: B

Rationale: The correct time for the nurse to initiate discharge planning for a client experiencing an exacerbation of heart failure is as soon as the client's condition is stable. Discharge planning should begin early in the admission process to ensure a smooth transition and continuity of care. While involving the client's family in the planning process is crucial, the primary focus should be on starting the preparations for discharge once the client's immediate health concerns are addressed and their condition is stable. Waiting for a team conference or after consulting with the family may delay the planning process, which is not ideal in ensuring a timely and effective discharge plan.