A nurse is caring for a patient who is symptomatic with a blood glucose level of 55 mg/dL. Which nursing intervention should be implemented first to effectively manage this hypoglycemic episode?
Administer 15 grams of oral glucose and recheck blood glucose in 15 minutes.
Notify the healthcare provider to order an intravenous insulin infusion.
Place the patient on a cardiac monitor to observe for arrhythmias before treating hypoglycemia.
Prepare to administer injectable glucagon after obtaining blood glucose levels.
The Correct Answer is A
This question addresses the acute clinical management of hypoglycemia in a symptomatic patient. It requires applying the standard "Rule of 15" protocol, which is the evidence-based approach to rapidly raise blood glucose levels and restore homeostatic function while preventing further neuroglycopenic complications.
Choice A rationale
The Rule of 15 is the standard of care for conscious patients with hypoglycemia. Administering 15 grams of fast-acting carbohydrates followed by retesting in 15 minutes allows the body to restore glucose levels safely while preventing dangerous rebound hyperglycemia.
Choice B rationale
Administering insulin during a hypoglycemic episode is contraindicated and would cause a life-threatening, profound further drop in blood glucose levels. Insulin therapy is used to manage hyperglycemia, not to treat low blood sugar levels below 70 mg/dL.
Choice C rationale
Cardiac monitoring is secondary to the immediate need to treat the hypoglycemia. While severe hypoglycemia can impact cardiac rhythm, the primary intervention must be the correction of the glucose deficit to stabilize the patient's metabolic state and prevent neurological collapse.
Choice D rationale
Injectable glucagon is indicated when a patient is unconscious or unable to swallow safely. For a conscious, symptomatic patient, oral glucose is the first-line, least invasive, and most rapidly available treatment method to restore blood glucose to normal ranges.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This question tests clinical judgment regarding life-threatening adverse reactions to vancomycin. It requires identifying the signs of an anaphylactic or severe infusion-related reaction, which necessitates immediate intervention to maintain the patient's airway, breathing, and circulation, as these symptoms indicate critical physiological instability.
Choice A rationale
Phlebitis is a localized inflammatory reaction of the vein wall. While it requires assessment and site rotation to prevent further tissue damage, it is a localized complication and does not represent a life-threatening systemic emergency.
Choice B rationale
Flushing, hypotension, and wheezing are cardinal signs of an anaphylactic reaction. These systemic symptoms indicate severe bronchospasm and cardiovascular collapse, requiring immediate cessation of the infusion, administration of epinephrine, and urgent medical management to prevent patient mortality.
Choice C rationale
Mild tinnitus is a known side effect related to vancomycin's potential ototoxicity, which is usually dose-related and progressive. While it warrants monitoring and potential dose adjustment, it does not represent an immediate systemic emergency that requires emergency intervention.
Choice D rationale
Mild myalgia and vertigo can occur following vancomycin administration but are not indicative of an immediate, life-threatening crisis. They require monitoring and documentation, but the patient remains hemodynamically stable, making this a secondary priority compared to anaphylaxis.
Correct Answer is C
Explanation
This question defines key pharmacological terms related to the drug response cycle. It requires distinguishing the concept of "onset of action" from other pharmacokinetic parameters like peak level or duration, which is essential for timing medication administration for optimal therapeutic benefit in patients.
Choice A rationale
The duration of action refers to the period during which a drug concentration is sufficient to elicit a therapeutic response. This is distinct from the onset, which measures the time taken to reach the minimum effective concentration required for efficacy.
Choice B rationale
The peak effect represents the time required for a drug to reach its maximum therapeutic response. This occurs after the onset of action and relates to the maximum concentration of the drug at the site of its intended receptor.
Choice C rationale
The onset of action is the specific time interval between the administration of a drug and the first appearance of its therapeutic effect. It marks the point when the drug concentration reaches the minimum level needed for a clinical response.
Choice D rationale
The number of doses required to achieve a therapeutic effect is related to the drug's half-life and the concept of steady-state concentration. It is not the definition of the onset of action, which describes the timing of the initial drug response.
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