An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The patient reports feeling very weak and jittery. What actions should the nurse take? (Select all that apply)

Choice A rationale Checking the fingerstick glucose level is an immediate action that the nurse should take when a patient with type 2 diabetes reports feeling weak and jittery. These symptoms could indicate hypoglycemia, a condition characterized by low blood sugar levels. Choice B rationale Assessing skin temperature and moisture can help the nurse determine if the patient is sweating, a common symptom of hypoglycemia. Choice C rationale Administering a PRN dose of regular insulin is not the appropriate action if the patient is experiencing symptoms of hypoglycemia. Insulin would further lower the patient’s blood sugar levels, potentially worsening their condition. Choice D rationale Documenting anxiety on the surgical checklist may not be immediately helpful in addressing the patient’s current symptoms. While it’s important to document all relevant information, the nurse’s immediate focus should be on assessing and managing the patient’s symptoms. Choice E rationale Measuring pulse and blood pressure can provide important information about the patient’s cardiovascular status. Hypoglycemia can cause tachycardia and potentially hypotension, so these vital signs should be monitored.