A nurse assesses a patient with diabetes mellitus and notes that the patient only responds to a sternal rub by moaning, has a capillary blood glucose of 33 mg/dL (1.8 mmol/L), and has an intravenous line that is infiltrated with 0.45% normal saline. What action would the nurse take first?

Administer 25 mL of dextrose 50% IVP

Encourage the patient to drink orange juice

Insert a new intravenous access line

Administer 1 mg of IM glucagon

Answer and Explanation

The Correct Answer is C

Choice A reason: Administering 25 mL of dextrose 50% IVP would rapidly elevate blood glucose by delivering concentrated glucose, critical for severe hypoglycemia. However, an infiltrated IV line prevents effective delivery, risking extravasation and tissue damage. This action is ineffective without a functional IV, delaying treatment for the patient’s life-threatening low glucose state, which can lead to seizures or coma.

Choice B reason: Encouraging orange juice intake is inappropriate for a patient with altered consciousness, responding only to a sternal rub. Severe hypoglycemia impairs swallowing, increasing aspiration risk. Oral glucose is too slow to correct critical hypoglycemia, requiring immediate parenteral intervention to restore glucose levels and prevent neurological damage or death in this emergency.

Choice C reason: Inserting a new intravenous access line is the priority because the current line is infiltrated, preventing delivery of medications or fluids. A functional IV ensures rapid administration of dextrose to correct severe hypoglycemia. This action addresses the immediate barrier to treatment, enabling life-saving interventions to stabilize the patient’s critically low blood glucose levels effectively.

Choice D reason: Administering 1 mg of IM glucagon stimulates glycogenolysis to release stored glucose, a viable option when IV access is unavailable. However, it is slower than IV dextrose and less effective in patients with depleted glycogen stores, common in severe hypoglycemia. Establishing IV access is prioritized for faster, more reliable glucose delivery in this critical situation.

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Correct Answer is D

Explanation

Choice A reason: A glucose level of 500 mg/dL is elevated but not specific to HHS, which typically involves glucose >600 mg/dL. Both DKA and HHS feature hyperglycemia, but HHS is distinguished by higher glucose and osmolarity without significant ketosis. This level alone does not confirm HHS over other hyperglycemic states.

Choice B reason: Ketosis is characteristic of DKA, not HHS. HHS involves extreme hyperglycemia and hyperosmolarity with minimal ketone production due to sufficient insulin to prevent ketogenesis but not hyperglycemia. The absence of significant ketosis distinguishes HHS, making this an incorrect indicator for this condition.

Choice C reason: Hypertension is not a defining feature of HHS. HHS causes dehydration from osmotic diuresis, often leading to hypotension, not hypertension. While stress responses may elevate blood pressure, it is not a diagnostic criterion. Hyperosmolarity and hyperglycemia are the hallmarks, making this choice irrelevant to HHS diagnosis.

Choice D reason: Plasma osmolarity of 350 mOsm/L is a key indicator of HHS, which is defined by extreme hyperglycemia (>600 mg/dL) and hyperosmolarity (>320 mOsm/L). Osmotic diuresis from glucose causes dehydration, elevating osmolarity, leading to neurological symptoms like confusion. This distinguishes HHS from DKA, confirming the diagnosis.

A. Obtain vital signs every hour postprocedure B. Have the patient void C. Check for a signed consent form D. Post-procedure, encourage early ambulation E. Send fluid for lab analysis

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Obtaining vital signs every hour post-paracentesis monitors for complications like bleeding or hypovolemia, as the procedure removes peritoneal fluid, potentially causing hemodynamic instability. Frequent monitoring ensures early detection of hypotension, tachycardia, or other signs of complications, ensuring patient safety after this invasive procedure targeting spontaneous bacterial peritonitis.

Choice B reason: Having the patient void before paracentesis prevents bladder puncture, as a full bladder elevates the risk during needle insertion into the peritoneal cavity. Emptying the bladder ensures a safer procedure by reducing the risk of organ injury, a critical step in preparing for paracentesis to diagnose spontaneous bacterial peritonitis.

Choice C reason: Checking for a signed consent form is essential, as paracentesis is an invasive procedure requiring informed consent. This ensures the patient understands risks, benefits, and alternatives, adhering to ethical and legal standards. Confirming consent is a critical pre-procedure step to diagnose spontaneous bacterial peritonitis safely and appropriately.

Choice D reason: Encouraging early ambulation post-paracentesis is not standard, as patients may require monitoring for complications like bleeding or hypotension. Rest is typically advised initially to ensure stability. Ambulation may increase intra-abdominal pressure or risk complications, making it inappropriate in the immediate post-procedure care plan for this condition.

Choice E reason: Sending fluid for lab analysis is critical in paracentesis to diagnose spontaneous bacterial peritonitis. The fluid is tested for cell count, bacteria, and protein to confirm infection. This analysis guides antibiotic therapy and management, making it an essential component of the care plan to address the suspected bacterial infection.

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A nurse assesses a patient with diabetes mellitus and notes that the patient only responds to a sternal rub by moaning, has a capillary blood glucose of 33 mg/dL (1.8 mmol/L), and has an intravenous line that is infiltrated with 0.45% normal saline. What action would the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has type 2 diabetes mellitus and their glucose levels are rising. Which of the following would indicate the patient is in a hyperosmolar hyperglycemic state (HHS)?

Correct Answer is D

Explanation

The nurse reviews the chart and signs the order: “Paracentesis now, to rule out spontaneous bacterial peritonitis.” What will the nurse include in the plan of care? (Select all that apply)

Correct Answer is ["A","B","C","E"]

Explanation

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