Physiological Adaptation Practice Question

Question

The nurse is caring for a client with heart failure and is focused on diabetes complications scenario 4. Which nursing action is most appropriate?

Answer choices

1. A. Delay assessment until the next scheduled round if the client is not calling for help.
2. B. Recognize hypoglycemia and hyperglycemia and intervene promptly.
3. C. Delegate the clinical assessment and nursing judgment to assistive personnel.
4. D. Document the concern without notifying the appropriate provider or care team member when escalation is needed.

Correct Answer

B. Recognize hypoglycemia and hyperglycemia and intervene promptly.

Explanation

The priority action for diabetes complications is to recognize hypoglycemia and hyperglycemia and intervene promptly. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

• Difficulty: medium
• Domain: Physiological Adaptation
• Objective: diabetes complications

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