A nurse is assessing a client who has diabetes mellitus and reports feeling dizzy and weak. Which of the following actions should the nurse take?
Check blood glucose level.
Give insulin injection.
Offer orange juice.
Apply cold compress.
The Correct Answer is A
Choice A reason: Checking blood glucose level is an appropriate action for the nurse to take because it can help determine if the client has hypoglycemia or hyperglycemia, which are both complications of diabetes mellitus that can cause dizziness and weakness. Blood glucose level should be checked using a glucometer and compared with the normal range of 70 to 130 mg/dL before meals and less than 180 mg/dL after meals.
Choice B reason: Giving insulin injection is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hypoglycemia, which is a condition in which blood glucose level drops below 70 mg/dL and can cause dizziness, weakness, confusion, sweating, and seizures. Insulin injection should be given according to the prescribed dose, type, and schedule.
Choice C reason: Offering orange juice is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hyperglycemia, which is a condition in which blood glucose level rises above 180 mg/dL and can cause dizziness, weakness, thirst, polyuria, and ketoacidosis. Orange juice should be offered only if the client has hypoglycemia and is conscious and able to swallow.
Choice D reason: Applying cold compress is not an appropriate action for the nurse to take because it does not address the underlying cause of dizziness and weakness in a client who has diabetes mellitus. Cold compress may worsen the symptoms by reducing blood flow and oxygen delivery to the brain. Cold compress should be applied only if the client has fever, inflammation, or pain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Creatinine 0.8 mg/dL is within the normal range (0.6-1.2), and it does not indicate fluid volume excess. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. High creatinine levels can indicate kidney damage or impaired renal function.
Choice B reason: Hgb 15 g/dL is within the normal range (13-17 for men, 12-16 for women), and it does not indicate fluid volume excess. Hgb stands for hemoglobin, which is a protein in red blood cells that carries oxygen to the tissues. Low hemoglobin levels can indicate anemia, bleeding, or hemolysis.
Choice C reason: BUN 18 mg/dL is within the normal range (7-20), and it does not indicate fluid volume excess. BUN stands for blood urea nitrogen, which is a waste product of protein metabolism that is filtered by the kidneys. High BUN levels can indicate dehydration, kidney damage, or high protein intake.
Choice D reason: Sodium 149 mEq/L is high and indicates fluid volume excess. Sodium is an electrolyte that helps maintain fluid balance, blood pressure, and nerve impulses. High sodium levels can cause fluid retention, edema, hypertension, and heart failure.
Correct Answer is C
Explanation
Choice A reason: Tuna can is not a safe food choice for a client who has food allergies because it may contain traces of other fish or shellfish that can trigger an allergic reaction. Tuna can should be avoided or checked for allergen labels before consuming.
Choice B reason: Gravy beef is not a safe food choice for a client who has food allergies because it may contain gluten, soy, or dairy products that can trigger an allergic reaction. Gravy beef should be avoided or checked for allergen labels before consuming.
Choice C reason: Apple pie is a safe food choice for a client who has food allergies because it is unlikely to contain common allergens, such as nuts, eggs, or milk. Apple pie is made from cooked apples, sugar, flour, and butter, which are low-risk ingredients for food allergies. Apple pie should be stored in the refrigerator or freezer after cooling to prevent spoilage.
Choice D reason: Bread is not a safe food choice for a client who has food allergies because it may contain gluten, wheat, or sesame seeds that can trigger an allergic reaction. Bread should be avoided or checked for allergen labels before consuming.
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