A nurse is teaching the partner of a client who has diabetes mellitus how to manage episodes of severe hypoglycemia when the client is unresponsive.
Which of the following actions should the nurse instruct the partner to take first?

Administer glucagon IM to the client.

Call emergency medical services.

Check the client’s blood glucose level.

Transport the client to the emergency department.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Administering glucagon IM is the first action in managing severe hypoglycemia when the client is unresponsive. Glucagon stimulates the liver to release stored glucose, increasing blood glucose levels rapidly.

Choice B rationale

While calling emergency medical services is important, it is not the first action. Immediate administration of glucagon is crucial to prevent prolonged hypoglycemia and potential complications.

Choice C rationale

Checking the client's blood glucose level is important but should follow the administration of glucagon. Rapid intervention with glucagon can prevent worsening symptoms and stabilize the client.

Choice D rationale

Transporting the client to the emergency department is necessary if the condition does not improve. However, immediate glucagon administration is the priority to quickly elevate blood glucose levels. .

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Correct Answer is ["100"]

Explanation

To determine the infusion rate.

Step 1 is (100 mL ÷ 60 min) × 60 min/hr.

Step 2 is (100 mL ÷ 60 min) = 1.67 mL/min.

Step 3 is 1.67 mL/min × 60 min/hr = 100 mL/hr.

Step 4 is to round the answer to the nearest whole number, which is 100.

Answer: 100 mL/hr.

A. Temperature 37.9°C (100.2°F) B. Heart rate 97/min C. Respiratory rate 24/min D. Blood pressure 135/73 mmHg E. Oxygen saturation 88% on room air F. Pain 6 on a 0 to 10 scale

Correct Answer is ["A","C","E"]

Explanation

Choice A rationale: This temperature indicates a low-grade fever. Although not immediately life-threatening, it may suggest an underlying infection or inflammation that requires attention, especially given the client's other symptoms and elevated WBC count.

Choice B rationale: A heart rate of 97/min is slightly elevated but within the upper range of normal limits (60–100 bpm). This finding alone does not necessarily require immediate follow-up, especially without more severe symptoms.

Choice C rationale: A respiratory rate of 24/min is above the normal range (12–20 breaths/min) and may indicate respiratory distress or an underlying condition. The elevated rate, combined with low oxygen saturation, requires prompt follow-up.

Choice D rationale: The blood pressure reading of 135/73 mmHg is considered prehypertensive (normal range: <120/80 mmHg). While monitoring is essential, it does not immediately require follow-up in the context of other, more urgent issues.

Choice E rationale: An oxygen saturation of 88% on room air is significantly below the normal range (95–100%) and indicates hypoxemia. This requires immediate attention to address potential respiratory failure or other underlying causes.

Choice F rationale: Pain rated at 6 on a 0 to 10 scale is concerning but requires contextual evaluation. While high pain levels warrant attention, they are not immediately life-threatening compared to hypoxemia and respiratory distress.

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A nurse is teaching the partner of a client who has diabetes mellitus how to manage episodes of severe hypoglycemia when the client is unresponsive.Which of the following actions should the nurse instruct the partner to take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["100"]

Explanation

A nurse is caring for a 60-year-old male client in a provider’s clinic. Exhibits Click to select all the findings that require immediate follow-up.

Correct Answer is ["A","C","E"]

Explanation

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A nurse is teaching the partner of a client who has diabetes mellitus how to manage episodes of severe hypoglycemia when the client is unresponsive.
Which of the following actions should the nurse instruct the partner to take first?