A client tells the nurse about experiencing symptoms of a hypoglycemic insulin reaction. Which action should the nurse take FIRST?

Give the client juice or hard candy immediately.

Call the health care provider.

Have the client lie down and see if symptoms subside.

Assess the blood glucose level, and administer glucose in the most appropriate form.

Answer and Explanation

The Correct Answer is D

A. Give the client juice or hard candy immediately: While giving juice or hard candy is an appropriate treatment for hypoglycemia, assessing the blood glucose level first is crucial to confirm that the symptoms are indeed due to low blood sugar.

B. Call the health care provider: While it's important to notify the healthcare provider if the situation worsens or if there's a concern about the client's safety, the first priority is to assess the blood glucose level and take immediate action to treat the hypoglycemia.

C. Have the client lie down and see if symptoms subside: Lying down does not address the underlying cause of hypoglycemia. The client may need glucose to raise their blood sugar levels, so this is not the most effective first action.

D. Assess the blood glucose level, and administer glucose in the most appropriate form: Assessing the blood glucose level will confirm whether the symptoms are indeed due to hypoglycemia, and then the nurse can proceed with administering glucose in the most appropriate form (such as oral glucose, juice, or glucose tablets).

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Correct Answer is B

Explanation

A. Use sliding scale insulin to manage hypoglycemia: Sliding scale insulin is used to manage hyperglycemia, not hypoglycemia. Sick day management focuses on maintaining stable blood glucose levels, not using sliding scale insulin for hypoglycemia.

B. Continue taking the scheduled insulin or oral hypoglycemic agent: During illness, it is essential for clients with diabetes to continue their medication as prescribed. This helps prevent both hyperglycemia and ketosis, which can occur due to illness-induced stress.

C. Increase intake of carbohydrates for the duration of the illness: It is not necessary to increase carbohydrate intake unless the client is unable to eat enough food. It’s more important to maintain hydration and monitor blood glucose levels, adjusting insulin doses as needed.

D. Report blood glucose lower than 100 mg/dL to the health care provider: Blood glucose levels below 100 mg/dL are generally considered within normal range. During illness, clients may experience higher blood glucose levels, which are more concerning.

A. diabetic ketoacidosis B. hypoglycemia C. rebound hyperglycemia D. an insulin reaction

Correct Answer is A

Explanation

A. Diabetic ketoacidosis (DKA): DKA occurs when there is a lack of insulin, and the body starts breaking down fat for fuel, producing ketones. This leads to fruity breath, deep respirations (Kussmaul breathing), and dry, hot skin due to dehydration.

B. Hypoglycemia: Hypoglycemia presents with shakiness, sweating, and dizziness, but it does not cause fruity breath or deep respirations. These symptoms are more typical of DKA, which involves metabolic acidosis and abnormal respiratory patterns.

C. Rebound hyperglycemia: Rebound hyperglycemia, or the Somogyi effect, results from low blood sugar during the night, leading to a counter-regulatory hormone response. It does not cause fruity breath or deep respirations, which are characteristic of DKA.

D. An insulin reaction: An insulin reaction usually refers to hypoglycemia, characterized by symptoms like shakiness, sweating, and confusion. It does not explain the abdominal pain, fruity breath, or deep respirations, all indicative of DKA.

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A client tells the nurse about experiencing symptoms of a hypoglycemic insulin reaction. Which action should the nurse take FIRST?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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