A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

increased urine output

Cold, clammy skin

Acetone breath

Kussmaul respirations

Answer and Explanation

The Correct Answer is B

A) Increased urine output: This finding is more commonly associated with hyperglycemia and diabetic ketoacidosis, where the body attempts to excrete excess glucose through urine. In hypoglycemia, urine output is typically not increased.

B) Cold, clammy skin: This is a classic symptom of hypoglycemia. As blood sugar levels drop, the body releases adrenaline, which can cause sweating and result in cold, clammy skin. This finding directly supports the suspicion of hypoglycemia.

C) Acetone breath: This is associated with diabetic ketoacidosis, a complication of uncontrolled hyperglycemia. The presence of acetone on the breath indicates the breakdown of fat for energy, not a low blood sugar state.

D) Kussmaul respirations: These deep, labored breaths are typically seen in metabolic acidosis, particularly in diabetic ketoacidosis. They are not indicative of hypoglycemia.

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Correct Answer is C

Explanation

A. Diphenhydramine: This is an antihistamine primarily used to treat allergies and as a sedative. It is not indicated for reversing opioid-induced respiratory depression and could potentially worsen the sedation.

B. Flumazenil: This medication is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines. It is not effective for opioid overdose or respiratory depression caused by morphine.

C. Naloxone: Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, including respiratory depression. In cases of opioid-induced respiratory depression, naloxone is the appropriate medication to administer to restore normal respiratory function.

D. Calcium gluconate: This medication is used for conditions such as hypocalcemia or magnesium toxicity, but it is not relevant for opioid overdose or respiratory depression.

A. Alert the emergency response team. B. Cover the area with sterile normal saline-soaked gauze. C. Place the head of the client's bed at a 15° angle. D. Prepare the client for surgery.

Correct Answer is B

Explanation

A) Alert the emergency response team: While alerting the team is important, it should not be the first action taken. Immediate care to protect the client’s integrity is the priority before involving additional personnel.

B) Cover the area with sterile normal saline-soaked gauze: This is the most immediate and critical action. Covering the exposed bowel with sterile saline-soaked gauze helps to prevent infection and keeps the tissue moist, which is essential until surgical intervention can be performed.

C) Place the head of the client's bed at a 15° angle: While positioning the client can help with comfort and possibly reduce further protrusion, it is not the priority action in this emergency situation. The exposed bowel requires immediate protection.

D) Prepare the client for surgery: Preparing for surgery is a necessary step, but it should follow the immediate care for the exposed intestine. Ensuring that the bowel is covered and protected takes precedence.

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A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

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