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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A pump is usually needed to administer intermittent tube feedings, as it can control the flow rate and volume of the formula. A pump can also prevent overfeeding, aspiration, or diarrhea.
Choice B reason: Administering feedings over 10 to 20 minutes is too fast, as it can cause abdominal cramps, nausea, vomiting, or dumping syndrome. Intermittent tube feedings should be administered over 30 to 60 minutes.
Choice C reason: Administering feedings while sleeping at night is not recommended, as it can increase the risk of aspiration, reflux, or infection. Intermittent tube feedings should be administered during waking hours and with the head of the bed elevated at least 30 degrees.
Choice D reason: Advancing the rate of feedings slowly is advisable, as it can help the body adjust to the formula and prevent intolerance or complications. The rate should be increased gradually until the desired goal is reached.
Correct Answer is C
Explanation
Choice A reason: Dilute formula with 1 tablespoon of water is not a correct instruction for GER. Diluting formula can reduce the nutritional value and increase the volume of the feedings, which can worsen GER symptoms and cause dehydration and malnutrition.
Choice B reason: Place the newborn in a side-lying position if vomiting is not a correct instruction for GER. This position can increase the risk of aspiration, which is the inhalation of vomit into the lungs. Aspiration can cause pneumonia, respiratory distress, and death.
Choice C reason: Position the newborn at a 20-degree angle after feeding is a correct instruction for GER. This position can help prevent reflux by using gravity to keep the stomach contents down. The newborn should be kept upright for at least 30 minutes after each feeding.
Choice D reason: Provide a small feeding just before bedtime is not a correct instruction for GER. This can increase the likelihood of reflux during sleep, as the stomach will be full and prone to regurgitation. The last feeding should be given at least 2 to 3 hours before bedtime.
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