A client on glipizide, a sulfonylurea, reports to the nurse feeling anxious, sweaty & has a headache. The nurse's initial action is to:
take vital signs.
administer 1 mg glucagon subcutaneously.
obtain a blood glucose reading.
notify the physician.
The Correct Answer is C
A. While taking vital signs can provide useful information about the client's overall condition, it does not address the immediate concern of potential hypoglycemia. The priority is to assess blood glucose levels directly.
B. Glucagon can be administered in cases of severe hypoglycemia where the patient is unable to ingest glucose orally. However, before administering glucagon, the nurse should first check the blood glucose level to confirm hypoglycemia.
C. Checking the blood glucose level will provide immediate information about whether the client is experiencing hypoglycemia. If the blood glucose is low, appropriate treatment (such as administering glucose or a fast-acting carbohydrate) can be initiated. If it’s within normal limits, other causes for the symptoms can be explored.
D. While it may be necessary to notify the physician depending on the outcome of the blood glucose reading or if the client’s condition worsens, it is not the first action. Immediate assessment of the blood glucose level is essential to determine the correct course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While it is important to maintain a clean and dry dressing, changing it immediately may not be necessary at this stage. The small amount of bloody drainage could be a normal postoperative finding, and changing the dressing could disturb the surgical site.
B. While it is important to keep the physician informed of any changes, in this case, a small amount of bloody drainage may not warrant immediate notification unless it becomes excessive or is accompanied by other concerning symptoms.
C. Lowering the head of the bed might not directly address the situation. It may be more appropriate if the patient shows signs of hypotension or distress, but there is no indication that the drainage has caused such a concern at this moment.
D. Marking the area of drainage allows for proper monitoring of the situation. It helps track whether the drainage increases, remains the same, or decreases over time. Documentation of the time and date also provides a clear record for the healthcare team regarding the postoperative course, which is essential for ongoing assessment.
Correct Answer is ["12.5"]
Explanation
1 kilogram equals 2.2 pounds.
110 lbs, which is equivalent to 50 kg (110 lbs / 2.2).
The prescribed dose is 2 mg/kg/day, so the total daily dose is 100 mg (2 mg/kg * 50 kg). This total daily dose is divided into four doses, which means each dose is 25 mg (100 mg / 4).
The medication is supplied as 10 mg/5 mL, so for a 25 mg dose, the nurse will administer 12.5 mL (25 mg * (5 mL / 10 mg)). Therefore, the nurse will administer 12.5 mL per dose.
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