A nurse is providing teaching to a client who has type 1 diabetes mellitus and her partner about how to manage severe hypoglycemia at home. Which of the following actions should the nurse instruct the partner to perform first?
Offer the client a small meal if she is not nauseated.
Administer 1 mg of glucagon intramuscularly to the client.
Contact the client's provider for further instructions
Transport the client to an emergency department for treatment.
The Correct Answer is B
A) Offer the client a small meal if she is not nauseated:
While eating a small meal can help raise blood glucose levels, it is not the immediate priority in a severe hypoglycemia situation. The client might be unconscious or unable to swallow safely, making this action inappropriate as a first step.
B) Administer 1 mg of glucagon intramuscularly to the client:
Administering glucagon intramuscularly is the most crucial initial action. Glucagon rapidly increases blood glucose levels by stimulating glycogen breakdown in the liver. This is vital for quickly reversing severe hypoglycemia, especially if the client is unconscious or unable to ingest carbohydrates orally.
C) Contact the client's provider for further instructions:
Contacting the provider is essential, but it should occur after addressing the immediate hypoglycemic episode. Once the client's condition stabilizes, further guidance can be sought from the healthcare provider.
D) Transport the client to an emergency department for treatment:
Transporting the client to the emergency department is necessary if the hypoglycemia does not improve after administering glucagon or if the client remains unresponsive. However, it is not the first action; immediate glucagon administration takes precedence to stabilize the client's condition before considering transportation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "Clean the canister and cap of the inhaler every 2 weeks": While it's important to keep the inhaler clean, it should be cleaned more frequently than every 2 weeks. Typically, cleaning is recommended at least once a week to prevent medication buildup and ensure proper functioning.
B) "Wait 1 minute between puffs of the inhaler": Waiting 1 minute between puffs allows the medication from the first puff to take effect and opens the airways, making the second puff more effective. This practice helps maximize the medication's absorption and effectiveness.
C) "Tilt your head forward and inhale rapidly while depressing the canister": The correct technique involves tilting the head slightly back, not forward, to open the airways better. Additionally, the client should inhale slowly and deeply, rather than rapidly, to ensure the medication is properly delivered to the lungs.
D) "Place your middle finger at the mouthpiece and your thumb at the top of the inhaler": This description of finger placement is incorrect. The correct technique is to place the thumb at the base of the inhaler and the index and middle fingers on the top of the canister to allow for proper grip and activation of the inhaler.
Correct Answer is D
Explanation
A) "Limit sodium intake to 3,500 milligrams per day.":
Limiting sodium intake is crucial for managing heart failure to prevent fluid retention and exacerbation of symptoms. However, the recommended limit is typically much lower, around 1,500 to 2,000 milligrams per day, not 3,500 milligrams.
B) "Take ibuprofen for discomfort.":
Ibuprofen and other NSAIDs are not recommended for clients with heart failure as they can cause fluid retention, worsen heart failure symptoms, and increase the risk of kidney problems. Alternatives such as acetaminophen are generally safer for pain relief.
C) "Increase the distance you walk by 100 feet daily, even if you feel fatigued.":
While regular exercise is important, clients with heart failure should not push through fatigue, as overexertion can lead to worsening symptoms. Exercise recommendations should be tailored to the individual's tolerance and should be adjusted based on their energy levels.
D) "Include no more than 2,000 milliliters of fluid intake in 24 hours.":
Restricting fluid intake to 2,000 milliliters per day helps prevent fluid overload, which is critical for managing heart failure. Monitoring and limiting fluid intake can help control symptoms such as edema and shortness of breath.
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