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 B

Explanation

A. Client report of pain at the incision site: Pain is expected after a thyroidectomy and can be managed with analgesics. While discomfort can affect recovery, it does not indicate an immediate life-threatening complication.

B. High-pitched sound on inspiration: Stridor suggests airway obstruction due to laryngeal edema or tracheal compression, which can rapidly progress to respiratory distress. Immediate intervention, such as airway support or emergency intubation, is required to prevent asphyxiation.

C. Hypoactive bowel sounds: Decreased bowel sounds are common postoperatively due to anesthesia and immobility. This should be monitored for potential ileus but does not pose an immediate danger.

D. Loose tracheal secretions: Excess secretions may require suctioning, but they do not indicate a critical airway compromise like stridor does. Maintaining a clear airway is essential, but this finding alone is not an emergency.

A. Increase in urinary output B. Crackles on auscultation C. Intracranial pressure reading of 12 mm Hg D. Glasgow coma scale rating of 15

Correct Answer is B

Explanation

A. Increase in urinary output: Mannitol is an osmotic diuretic that promotes diuresis to reduce intracranial pressure (ICP). Increased urinary output is an expected effect and indicates the medication is working as intended.

B. Crackles on auscultation: Mannitol can lead to fluid overload, especially in clients with compromised renal or cardiac function. Crackles in the lungs suggest pulmonary edema, a serious adverse effect that should be reported immediately to prevent respiratory distress.

C. Intracranial pressure reading of 12 mm Hg: Normal ICP ranges from 5 to 15 mm Hg. A reading of 12 mm Hg is within the expected range and does not indicate an adverse effect of mannitol.

D. Glasgow coma scale rating of 15: A score of 15 indicates full consciousness and normal neurological function. This finding does not suggest an adverse reaction to mannitol.

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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 caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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