A nurse found a patient to be pale, diaphoretic, and lethargic. The capillary blood sugar was checked with the level of 39mg/dl. The patient is responsive and does not have any planned procedures. The nurse found the tube feeding was off. What intervention should the nurse plan to take?
Have the patient drink orange juice
Give 1 dose of glucagon SQ
Give the patient 3 sugar tablets
Give the patient 1 amp of IV Dextrose 50%
The Correct Answer is A
Rationale:
A. Have the patient drink orange juice: Since the patient is responsive and able to swallow safely, the priority is to provide a fast-acting carbohydrate like orange juice. This quickly raises blood glucose without invasive interventions.
B. Give 1 dose of glucagon SQ: Glucagon is indicated for severe hypoglycemia when the patient is unresponsive or unable to swallow. It is not the first-line intervention for a responsive patient.
C. Give the patient 3 sugar tablets: This is also an appropriate oral option for mild to moderate hypoglycemia, but orange juice works faster because it is liquid and more rapidly absorbed.
D. Give the patient 1 amp of IV Dextrose 50%: IV dextrose is reserved for severe hypoglycemia in patients who are unconscious or unable to take oral glucose safely. It is not necessary in this case since the patient is alert and can take oral carbs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Kaposi's sarcoma: Kaposi’s sarcoma typically presents as purplish, red, or brown macules, plaques, or nodules, often associated with immunocompromised states. It does not commonly present as a changing pigmented nevus with irregular shape or color variation.
B. Malignant melanoma: Malignant melanoma often arises from a pre-existing nevus or new pigmented lesion that shows asymmetry, irregular borders, color variation, and enlargement. These characteristics align with the client’s report of a growing, irregularly shaped, multicolored lesion.
C. Squamous cell carcinoma: Squamous cell carcinoma usually appears as a firm, red nodule or scaly lesion, sometimes ulcerated. It does not typically originate from a pigmented nevus and lacks the color variation described in this scenario.
D. Basal cell carcinoma: Basal cell carcinoma generally presents as pearly, translucent nodules or ulcers, often on sun-exposed areas. Changes in nevi with irregular shape and color are not characteristic of basal cell carcinoma.
Correct Answer is B
Explanation
Rationale:
A. Administer IV dextrose: IV dextrose is reserved for severe hypoglycemia, especially when the client is unconscious, unable to swallow, or experiencing seizures. Since the client is alert with only mild tremors, oral carbohydrate administration is safer and appropriate.
B. Administer 15 g of carbohydrates: A glucose level of 60 mg/dL is below normal, and symptoms of adrenergic response such as tremors indicate mild hypoglycemia. Providing 15 g of fast-acting carbohydrates, such as juice or glucose tablets, is the first-line treatment in a conscious client.
C. Administer 1 mg of glucagon IM: Glucagon is typically used in cases of severe hypoglycemia when IV access is unavailable and the client cannot safely ingest oral glucose. It is not necessary for this client who is alert and able to take oral carbohydrates.
D. Retest the blood glucose level: Retesting immediately without providing carbohydrates delays treatment and risks worsening hypoglycemia. Blood glucose should be rechecked 15 minutes after carbohydrate administration to ensure the level is rising appropriately.
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