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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Diabetic ketoacidosis (DKA) is a severe complication characterized by hyperglycemia, metabolic acidosis, and ketosis. Elevated glucose levels (typically >250 mg/dL) result from insufficient insulin. The body then breaks down fat for energy, producing ketones which lower the blood pH, resulting in metabolic acidosis. The expected finding is a low plasma bicarbonate level (normal range 22-29 mEq/L) reflecting the metabolic acidosis.
Choice B rationale: Decreased urine output is an incorrect finding. In DKA, hyperglycemia leads to osmotic diuresis, where excess glucose pulls water out of the body, leading to polyuria (increased urine output) and dehydration. The kidneys attempt to excrete the excess glucose and ketones, resulting in frequent and copious urination.
Choice C rationale: Increased respirations (Kussmaul respirations) are a compensatory mechanism for metabolic acidosis, but they lead to a decrease in pH, not an increase. The deep, rapid breathing attempts to blow off carbon dioxide, a form of carbonic acid, to raise the pH back to the normal range of 7.35-7.45.
Choice D rationale: While coma can be a late and severe complication of DKA, it is not a confirming diagnostic finding. DKA is confirmed by the specific biochemical triad of hyperglycemia, ketonemia/ketonuria, and metabolic acidosis. Patients are often awake and responsive in the early stages, experiencing symptoms like nausea, abdominal pain, and lethargy.
Correct Answer is B
Explanation
Choice A rationale: During an illness, the body is under stress, which can lead to increased blood glucose levels. To prevent dehydration and ketosis, it is critical to continue to consume fluids and carbohydrates, even if vomiting. Small, frequent sips of liquids containing electrolytes and sugar are often recommended to maintain hydration and energy.
Choice B rationale: Illness, stress, and dehydration can significantly alter blood glucose levels. Monitoring blood glucose at least every 4 hours allows for timely adjustments to insulin or oral medications, helping to prevent diabetic ketoacidosis or severe hypoglycemia. This frequent monitoring is a cornerstone of safe sick day management for clients with diabetes.
Choice C rationale: Even when vomiting, clients with type 1 diabetes must continue to take insulin to prevent diabetic ketoacidosis, which can be life-threatening. The dose may need adjustment based on frequent blood glucose monitoring, but it should not be discontinued. Clients with type 2 diabetes on oral agents may need a temporary switch to insulin.
Choice D rationale: Exercise can be beneficial for managing blood glucose, but during an acute illness, it is not recommended. The body's energy is needed to fight the infection. Intense physical activity can also increase the risk of dehydration and, in some cases, can paradoxically raise blood glucose levels, particularly if the client is already ill.
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