A client with type I diabetes mellitus has been prescribed a glucagon emergency kit for home use. When should the nurse instruct the client and family to administer glucagon?
Prior to meals to prevent hyperglycemia.
When symptoms of severe hypoglycemia are present.
When the client is unable to eat during sick days.
At the onset of symptoms of diabetic ketoacidosis.
The Correct Answer is B
Choice A rationale
Administering glucagon prior to meals to prevent hyperglycemia is not a recommended use of a glucagon emergency kit. Glucagon is a hormone that raises blood glucose levels by causing the liver to release stored glucose into the bloodstream. It is typically used to treat severe hypoglycemia (low blood sugar), not to prevent hyperglycemia (high blood sugar).
Choice B rationale
The nurse should instruct the client and family to administer glucagon when symptoms of severe hypoglycemia are present. Severe hypoglycemia is a potentially life-threatening condition that can cause symptoms such as confusion, blurred vision, seizures, and loss of consciousness. In such cases, glucagon can be administered to quickly raise the blood glucose level.
Choice C rationale
Administering glucagon when the client is unable to eat during sick days is not a recommended use of a glucagon emergency kit. While it’s true that illness can affect blood glucose levels,
glucagon is specifically used to treat severe hypoglycemia. Other strategies, such as adjusting insulin doses or consuming liquid or soft carbohydrates, are typically recommended when a person with diabetes is sick and unable to eat their usual meals.
Choice D rationale
Administering glucagon at the onset of symptoms of diabetic ketoacidosis is not a recommended use of a glucagon emergency kit. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Glucagon would not be effective in treating this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Eliminating spinach and other green vegetables from the diet is not necessary for a client taking dabigatran. Unlike warfarin, another anticoagulant that interacts with vitamin K found
in green leafy vegetables, dabigatran does not have this interaction. Therefore, clients taking dabigatran do not need to modify their intake of green vegetables.
Choice B rationale
The nurse should instruct the client to avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) while taking dabigatran. NSAIDs can increase the risk of bleeding, which is already elevated in clients taking anticoagulants like dabigatran.
Choice C rationale
Continuing to obtain scheduled laboratory bleeding tests is not necessary for a client taking dabigatran. Unlike some other anticoagulants, dabigatran does not require regular blood tests to monitor its effectiveness or adjust its dosage.
Choice D rationale
Keeping an antidote available in case of hemorrhage is not typically part of the teaching plan for a client taking dabigatran. While an antidote for dabigatran does exist, it is usually administered in a hospital setting in the event of life-threatening bleeding or emergency surgery.
Correct Answer is A
Explanation
Choice A rationale
Codeine is an opioid medication that can cause drowsiness and dizziness. This can increase the risk of falls, particularly in older adults or those with balance or mobility issues. Therefore, it is important to instruct the client to request assistance when ambulating to prevent falls.
Choice B rationale
While constipation is a common side effect of opioid medications like codeine, and a stool softener or laxative may be helpful in managing this side effect, it is not the highest priority nursing action. The risk of falls due to drowsiness or dizziness is a more immediate safety concern.
Choice C rationale
While it is important for the client to notify the nurse if the pain is not relieved, this is not the highest priority nursing action. The safety of the client is the primary concern, and preventing falls by providing assistance with ambulation is a more immediate need.
Choice D rationale
Advising the client that the medication should start to work in about 30 minutes is an important part of patient education, but it is not the highest priority nursing action. The safety of the client is the primary concern, and preventing falls by providing assistance with ambulation is a more immediate need.
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