A nurse is assessing a patient who has diabetes mellitus. Which of the following findings is a manifestation of hypoglycemia?
Bradycardia
Fruity odor on the client's breath
Vomiting
Cool, clammy skin
The Correct Answer is D
A. Bradycardia is not a typical sign of hypoglycemia; tachycardia is more common.
B. A fruity odor on the breath is a sign of diabetic ketoacidosis (DKA) (hyperglycemia).
C. Vomiting is more common in hyperglycemia/DKA rather than hypoglycemia.
D. Hypoglycemia presents with cool, clammy skin, sweating, confusion, and tremors due to the release of epinephrine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain a prescription for supplemental oxygen. – Correct Answer. Hypoxia must be corrected first to prevent tissue hypoxia and organ failure.
B. Obtain a prescription to administer intravenous fluids. – Incorrect. IV fluids are important but oxygenation is the priority.
C. Obtain a prescription to administer insulin. – Incorrect. Insulin corrects hyperglycemia but is not the first priority over oxygenation.
D. Obtain a prescription to check the patient’s glucose level. – Incorrect. While glucose monitoring is essential, treating hypoxia takes priority.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Answer: The nurse should first address the patient’s oxygen saturation followed by the patient’s hypotension.
Rationale:
1st Priority: Oxygen Saturation → The client’s oxygen saturation has dropped to 88% on room air, which is below the expected range (typically ≥95% in healthy individuals). Hypoxia must be addressed immediately to prevent further complications. The nurse should apply supplemental oxygen and reassess respiratory status.
2nd Priority: Hypotension → The client’s blood pressure has dropped to 94/59 mmHg, which is significantly lower than the earlier reading of 102/76 mmHg. This may contribute to dizziness and syncope. The nurse should monitor for signs of hemodynamic instability, assess for ongoing blood loss (related to heavy menstrual bleeding), and anticipate interventions such as IV fluids or further evaluation for anemia-related hypotension.
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