A nurse is caring for a client who has diabetes mellitus and cool, clammy skin. The client begins having a seizure. Which of the following treatments should the nurse administer?

Glucagon 1 mg IM

Continuous IV infusion of regular insulin

10 g of oral glucose gel

1 L bolus of 0.45% sodium chloride over 1 hr

Answer and Explanation

The Correct Answer is A

A. Glucagon 1 mg IM: Glucagon is used to treat severe hypoglycemia when the client is unconscious, having seizures, or unable to take oral glucose. It stimulates glycogen breakdown in the liver, raising blood glucose levels. IM administration is appropriate for rapid effect in an emergency.

B. Continuous IV infusion of regular insulin: Insulin lowers blood glucose levels, which would worsen hypoglycemia. Administering insulin in this situation is inappropriate and could exacerbate the client’s condition.

C. 10 g of oral glucose gel: Oral glucose is suitable for mild to moderate hypoglycemia in a conscious client. However, since the client is experiencing a seizure, they are unable to swallow safely, making this option unsafe.

D. 1 L bolus of 0.45% sodium chloride over 1 hr: Hypoglycemia is not primarily treated with IV fluids unless the client is severely dehydrated. The priority in this case is to correct the low blood glucose level rather than administering hypotonic fluids.

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Correct Answer is C

Explanation

A. Sore throat: A sore throat is a common and expected finding after extubation due to irritation and mild inflammation of the airway. While discomfort may persist, it does not typically require immediate intervention.

B. SaO2 92%: An oxygen saturation of 92% is slightly lower than normal but is generally acceptable in most patients following extubation. Close monitoring is necessary, but immediate intervention is not required unless the saturation continues to decline.

C. Stridor: Stridor is a high-pitched, harsh sound caused by upper airway obstruction, often due to post-extubation laryngeal edema. This is a medical emergency requiring immediate intervention, such as administration of nebulized epinephrine, corticosteroids, or reintubation if severe airway compromise occurs.

D. Rhonchi: Rhonchi are low-pitched, coarse lung sounds caused by mucus or secretions in the airways. This finding may indicate the need for suctioning or respiratory therapy but does not require urgent intervention compared to stridor.

A. Hospice care services B. Long-term care facility C. Rehabilitation center D. Visiting nurse services

Correct Answer is D

Explanation

A. Hospice care services: Hospice care is designed for clients with terminal illnesses who require end-of-life care. Crohn’s disease and an ileostomy do not indicate a terminal condition, making hospice services inappropriate for this client.

B. Long-term care facility: Long-term care facilities are for clients who need continuous medical or personal care and are unable to live independently. Most clients with an ileostomy can manage their care at home with proper education and support, making this resource unnecessary.

C. Rehabilitation center: Rehabilitation centers are primarily for clients recovering from major injuries, strokes, or surgeries that impair mobility or function. While an ileostomy requires adjustment, it does not typically necessitate inpatient rehabilitation.

D. Visiting nurse services: Home health nurses provide essential support for clients with a new ileostomy by assisting with ostomy care, monitoring for complications, and reinforcing self-care education. This service helps facilitate a smoother transition to independent ostomy management.

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A nurse is caring for a client who has diabetes mellitus and cool, clammy skin. The client begins having a seizure. Which of the following treatments should the nurse administer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately

Correct Answer is C

Explanation

A nurse is preparing discharge teaching for a client who has Crohn's disease and a new ileostomy. Which of the following community resources should the nurse include in the teaching?

Correct Answer is D

Explanation

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