NCLEX-PN Practice Test 9

Day 1, 1500: Admitted from the wound clinic for a left plantar foot ulcer with surrounding cellulitis. Ulcer under the first metatarsal head, 2.0 cm × 1.5 cm × 0.4 cm, pink-red base, moderate serous drainage, no odor. Redness extends 3 cm around the ulcer; border marked with a skin marker. Left foot warm; pedal pulses palpable 2+ bilaterally. Client states, "I didn't even know it was there until I saw drainage on my sock."

Day 1, 1800: Client nauseated; ate 25% of dinner. Glipizide given at 1730 before the tray arrived.

Day 1, 2100: Point-of-care glucose 112 mg/dL; no correction insulin needed. Insulin glargine 20 units given subcutaneously. Client declined the bedtime snack, stating, "I'm just not hungry."

0615: The AP reports that the client "is sweaty and not making sense." Client is diaphoretic with cool, clammy skin. Hands tremble when reaching for the call light. Oriented to person and place only; irritable and slow to answer questions. Heart rate 108/min; client states, "My heart is pounding." Swallows sips of water without coughing. Lungs clear bilaterally. Left foot dressing dry and intact; redness stays inside the border marked on admission. Point-of-care glucose 54 mg/dL. Client reports no pain in the left foot.

History and Physical (Day 1). Client, age 68, admitted with a left diabetic foot ulcer present for about 6 weeks, with cellulitis. Past medical history: type 2 diabetes mellitus for 15 years; peripheral neuropathy (burning and tingling in both feet at night, eased by gabapentin); chronic kidney disease stage 3b; hypertension; hyperlipidemia. Monofilament test: no sensation at 6 of 10 sites on each foot. Home medications: glipizide 10 mg PO twice daily; insulin glargine 20 units subcutaneously at bedtime; amlodipine 5 mg PO daily; atorvastatin 40 mg PO at bedtime; gabapentin 300 mg PO at bedtime. Allergies: no known drug allergies. Social: lives with spouse; retired bus driver; walks 1 mile most days in canvas sneakers; denies tobacco use. Weight 198 lb (90 kg). X-ray of left foot: no evidence of osteomyelitis.

Orders (Day 1): Consistent-carbohydrate diet (60 g carbohydrate per meal) with bedtime snack. Point-of-care glucose before meals and at bedtime. Insulin glargine 20 units subcutaneously at 2100. Glipizide 10 mg PO twice daily, 30 minutes before breakfast and dinner (0730 and 1730). Insulin lispro correction scale before meals and at bedtime: 151–200 mg/dL, 2 units; 201–250 mg/dL, 4 units; 251–300 mg/dL, 6 units; more than 300 mg/dL, 8 units and notify provider. Ampicillin-sulbactam 3 g IV piggyback every 6 hours (0000, 0600, 1200, 1800). Amlodipine 5 mg PO daily. Atorvastatin 40 mg PO at bedtime. Gabapentin 300 mg PO at bedtime. Heparin 5,000 units subcutaneously every 8 hours. Left foot: cleanse ulcer with 0.9% sodium chloride and apply a nonadherent foam dressing daily and as needed. No weight bearing on the left forefoot; up with walker and offloading shoe. Vital signs every 4 hours. Podiatry consult. HYPOGLYCEMIA PROTOCOL (glucose less than 70 mg/dL): If alert and able to swallow, give 15 g fast-acting carbohydrate (120 mL [4 oz] fruit juice or 4 glucose tablets) and recheck glucose in 15 minutes; repeat up to 2 more times while glucose stays below 70 mg/dL. When glucose is 70 mg/dL or higher, give a snack with 15 g carbohydrate plus protein if the next meal is more than 1 hour away. If unable to swallow safely or unresponsive, give glucagon 1 mg IM and call for the RN; dextrose 50% 25 mL IV push is given by the RN. Notify the provider of every glucose result below 70 mg/dL.