A nurse is assessing a previously alert client who has now become confused, lethargic, and does not follow commands appropriately.
The blood glucose measures 48 mg/dL. What is the appropriate nursing intervention?

Administer 40 ounces of fruit juice.

Administer 15 grams of simple carbohydrates in the form of hard candy.

Administer 50 mL of Dextrose 50% IV push.

Repeat the blood glucose test after 15 minutes.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Administering 40 ounces of fruit juice would result in excessive carbohydrate intake and is inappropriate for treating hypoglycemia. Standard treatment includes 15 grams of carbohydrates or intravenous glucose for severe symptoms.

Choice B rationale

Hard candy provides 15 grams of carbohydrates, suitable for a patient who is alert and able to safely swallow. However, this client exhibits confusion and lethargy, necessitating a quicker, safer IV intervention.

Choice C rationale

Administering Dextrose 50% IV push rapidly raises blood glucose levels, effectively treating hypoglycemia in symptomatic, confused, or unconscious patients. This intervention bypasses the gastrointestinal tract for immediate action.

Choice D rationale

Rechecking glucose after 15 minutes is essential after treatment but does not address acute hypoglycemia. Delaying treatment risks prolonged hypoglycemia, increasing the risk of neuronal injury or further clinical deterioration. .

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Correct Answer is A

Explanation

Choice A rationale

Vigorous coughing or nose blowing increases pressure in the middle ear, potentially dislodging the stapes prosthesis, interfering with healing, and increasing risk of complications like vertigo or auditory damage.

Choice B rationale

Packing with dry dressing is contraindicated because it may trap moisture and increase infection risk. If drainage occurs, sterile measures are taken to assess and manage infection without creating ideal conditions for pathogens.

Choice C rationale

Irrigation of the ear canal risks introducing pathogens or disrupting the surgical area. Post-surgery, maintaining a dry environment helps reduce infection and promote proper healing.

Choice D rationale

Though bedrest may be recommended initially, prolonged immobility isn't essential unless specific complications arise. Movement minimizes risks of clot formation and encourages circulation, aiding recovery.

A. Symmetry of extraocular movement. B. Both near and distant vision. C. Cloudiness in the lens of the eye. D. Intraocular pressure changes.

Correct Answer is B

Explanation

Choice A rationale

Symmetry of extraocular movements assesses cranial nerve function but does not relate to the corrective purpose of bifocals, which is addressing near and distant vision issues caused by presbyopia and myopia.

Choice B rationale

Bifocals correct presbyopia and myopia by combining lenses for near and distant vision in one frame. Effectiveness is assessed by evaluating improvements in both visual ranges, ensuring accommodation and refraction are properly corrected.

Choice C rationale

Cloudiness in the lens indicates cataracts, which bifocals cannot correct. Cataracts require surgical intervention, making this assessment irrelevant to determining bifocal lens effectiveness for presbyopia and myopia.

Choice D rationale

Intraocular pressure changes relate to glaucoma, not refractive issues like myopia or presbyopia. Monitoring for glaucoma requires tonometry, independent of bifocal lens evaluation.

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A nurse is assessing a previously alert client who has now become confused, lethargic, and does not follow commands appropriately.The blood glucose measures 48 mg/dL. What is the appropriate nursing intervention?

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A nurse is assessing a previously alert client who has now become confused, lethargic, and does not follow commands appropriately.
The blood glucose measures 48 mg/dL. What is the appropriate nursing intervention?