A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed and the pulse and respiratory rate are increased from the client's baseline. The nurse would first take which action?
Assist the RN to prepare an intravenous (IV) insulin infusion.
Give the client 4 oz of orange juice.
Check the client's capillary blood glucose.
Assist the RN to administer 50% dextrose.
The Correct Answer is C
Choice A Reason: Assisting the RN to prepare an IV insulin infusion is not the first action that the nurse should take, as it may not be appropriate for the client's condition without knowing the blood glucose level.
Choice B Reason: Giving the client 4 oz of orange juice is not the first action that the nurse should take, as it may worsen the client's condition if the blood glucose level is high.
Choice C Reason: Checking the client's capillary blood glucose is the first action that the nurse should take, as it helps to determine if the client has hyperglycemia or hypoglycemia and guides the appropriate intervention.
Choice D Reason: Assisting the RN to administer 50% dextrose is not the first action that the nurse should take, as it may be harmful for the client if the blood glucose level is high.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Ice cream is not a good food choice for a client who has cholecystitis, as it is high in fat and may trigger gallbladder pain or inflammation.
Choice B Reason: Blueberry muffin is not a good food choice for a client who has cholecystitis, as it may contain butter, oil, or eggs that are high in fat and may aggravate gallbladder symptoms.
Choice C Reason: Macaroni and cheese is not a good food choice for a client who has cholecystitis, as it is high in fat and cholesterol and may cause gallstone formation or obstruction.
Choice D Reason: Roast turkey is a good food choice for a client who has cholecystitis, as it is low in fat and high in protein and may help to prevent gallbladder attacks.
Correct Answer is B
Explanation
Choice A Reason: The procedure will not be cancelled if the urinalysis indicates the presence of red blood cells, but it may indicate a urinary tract infection or kidney damage that needs further evaluation.
Choice B Reason: After the procedure, you will be encouraged to drink plenty of fluids, as this helps to flush out the contrast dye that was injected into your vein and prevent dehydration and kidney damage.
Choice C Reason: High frequency sound waves will not be used to identify renal system structures, but this is the principle of ultrasound imaging, which is a different diagnostic test.
Choice D Reason: You will not need to remain flat in bed for 4 hours following this procedure, but you may need to rest for a short period of time and avoid strenuous activities for the rest of the day.
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