A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has a capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first?

Administer 1 mg of intramuscular glucagon.

Encourage the client to drink orange juice.

Insert a new intravenous access line.

Elevate the client's head of bed.

Answer and Explanation

The Correct Answer is A

Choice A rationale: The client's altered level of consciousness (responding only to a sternal rub) and severely low capillary blood glucose of 33 g/dL (normal range 70-110 mg/dL) indicate severe hypoglycemia. The IV line is infiltrated, making IV dextrose administration impossible. In this situation, intramuscular glucagon is the most rapid and effective intervention. It mobilizes hepatic glycogen stores to increase blood glucose levels, a critical and immediate action to prevent further neurological damage or death.
Choice B rationale: The client's decreased level of consciousness makes it unsafe to administer oral fluids like orange juice due to the high risk of aspiration. The client cannot swallow safely. This intervention would be appropriate for a client who is conscious and able to swallow, but not for one who only responds to a sternal rub.
Choice C rationale: While a new intravenous line is necessary for future care and potential IV dextrose administration, this is not the first action. The client's severe hypoglycemia requires an immediate increase in blood glucose. Inserting a new line takes time, and the delay could be fatal. Intramuscular glucagon is the fastest way to reverse the immediate threat.
Choice D rationale: Elevating the head of the bed may be a prudent action to maintain a patent airway and reduce the risk of aspiration. However, it is not the first priority. The client's life is at immediate risk from the profound hypoglycemia. The priority is to raise the blood glucose level, which intramuscular glucagon can accomplish rapidly.

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Correct Answer is C

Explanation

Choice A rationale: Tetany is a neuromuscular hyperexcitability disorder caused by hypocalcemia, which can be a complication of a thyroidectomy due to accidental removal or damage to the parathyroid glands. Symptoms include tingling sensations, muscle spasms, and carpopedal spasms. While a possible post-surgical complication, the client’s signs of high temperature, tachycardia, and restlessness point to a different, more severe condition.
Choice B rationale: Hypoglycemia is a state of low blood glucose, typically below 70 mg/dL. Symptoms include sweating, shakiness, confusion, and hunger. The client’s signs of a high temperature, tachycardia, and extreme restlessness are not classic symptoms of hypoglycemia. Furthermore, hypoglycemia is not typically a complication of a thyroidectomy unless the client has a pre-existing diabetic condition.
Choice C rationale: A thyroid crisis, or thyroid storm, is a life-threatening complication of hyperthyroidism that can be precipitated by surgery, particularly a thyroidectomy, in an inadequately prepared client. It is characterized by a massive release of thyroid hormones, leading to a hypermetabolic state with symptoms including extremely high fever, severe tachycardia, altered mental status, and cardiovascular collapse. The client's symptoms are classic signs of this condition.
Choice D rationale: Diabetic ketoacidosis (DKA) is a severe complication of uncontrolled diabetes mellitus characterized by hyperglycemia, metabolic acidosis, and ketone body production. Symptoms include fruity breath, abdominal pain, and Kussmaul respirations. A thyroidectomy is not a direct cause of DKA. The client’s signs and symptoms, particularly the very high temperature, are not typical of DKA.

A. Insulin is never given intravenously. B. Only regular insulin can be administered intravenously. C. Insulin aspart or insulin lispro can be administered intravenously, but there must be a 50% dose reduction. D. Insulin may be administered intravenously, but only in emergencies.

Correct Answer is B

Explanation

Choice A rationale: This statement is incorrect. Insulin can and is administered intravenously in specific clinical situations, particularly for managing diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). Intravenous administration allows for rapid and precise titration of insulin dosage to achieve stable blood glucose levels.
Choice B rationale: Regular insulin is the only type of insulin that can be administered intravenously. Its short duration of action and predictable profile make it ideal for titrating doses in a controlled hospital setting. Other types of insulin, such as rapid-acting or long-acting analogs, are not formulated for intravenous use and carry a risk of unpredictable effects.
Choice C rationale: Insulin aspart and insulin lispro are rapid-acting insulins designed for subcutaneous administration. They are not approved or recommended for intravenous use due to their formulation and the potential for dose-response unpredictability. There is no established protocol for administering these insulins intravenously, even with a dose reduction.
Choice D rationale: While intravenous insulin is often used in emergent situations like DKA or HHS, it is not limited to emergencies. It may also be used in other controlled settings, such as during surgery or in critical care, to manage hyperglycemia. Its use is based on the need for tight glycemic control rather than just emergency status.

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A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has a capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A client had a subtotal thyroidectomy in the early morning. During evening rounds, the nurse assesses the client who now has nausea, a temperature of 105 degrees F (40.6 C), tachycardia, and extreme restlessness. What is the most likely cause of these signs and symptoms?

Correct Answer is C

Explanation

The nurse is preparing to administer insulin intravenously. Which statement about the administration of intravenous insulin is true?

Correct Answer is B

Explanation

The complication of diabetic neuropathy places the client at risk for which of these conditions?

The nurse is teaching patients about self-injection of insulin. Which statement is true regarding injection sites?

A nurse is providing diabetic teaching for a family of a client newly diagnosed with diabetes. The nurse determines that the family understands the reason for having glucagon on hand for emergency home use if the family indicates that the purpose of the medication is to treat:

A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has a capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first?

The nurse is teaching a group of patients about management of diabetes. Which statement about basal dosing is correct?

A client tells the nurse that sometimes he gets lightheaded and shaky when he exercises. The nurse advised him to always:

Which of the following are complications of insulin therapy? (Select all that apply).

A mother reports that her 4-month-old infant is lethargic, sleeps 18 hours a day, and snores. The nurse recognizes these signs are characteristic of what?