A nurse is caring for a client who has a blood glucose of 52. The client is lethargic but arousable. Which of the following actions should the nurse perform first?
Provide a carbohydrate and protein food
Report the findings to the provider
Provide 15 grams of simple carbohydrates
Recheck blood glucose in 15 minutes
The Correct Answer is C
A. While this is appropriate for mild hypoglycemia, the patient is lethargic, indicating a more severe state.
B. While the provider should be notified, immediate intervention is necessary to treat the hypoglycemia.
C. A blood glucose of 52 is dangerously low, and the patient is exhibiting symptoms of severe hypoglycemia. Administering 15 grams of simple carbohydrates, such as glucose tablets or juice, is the quickest way to raise blood sugar levels.
D. While rechecking blood glucose is important, it is not the priority. Immediate intervention to raise blood sugar levels is crucial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While hyperglycemia is common after surgery, a blood sugar of 120 is not considered severely high.
B. Nausea is a common side effect of opioid pain medication and not specifically related to diabetes complications.
C. This is the most likely indicator of a severe complication, specifically Diabetic Ketoacidosis (DKA). Ketones in the blood and urine are characteristic of DKA, which can be life-threatening.
D. Postoperative soreness is expected.
Correct Answer is A
Explanation
A. The absence of wheezing in a patient with an acute asthma attack is a critical sign. It may indicate that the patient is deteriorating rapidly, and their airways are closing significantly. This is a life-threatening situation requiring immediate intervention.
B. A patient with an acute asthma attack would not be discharged without significant improvement and stabilization.
C. While it might seem like an improvement, the absence of wheezing in this context is a red flag and not a positive sign.
D. The patient may still require additional bronchodilators or other interventions.
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