A patient is recovering from an episode of diabetic ketoacidosis and reports feeling “anxious, shaky, and sweaty.”. What should be the nurse’s initial action?
Obtain a full set of vital signs.
Administer 1 mg glucagon subcutaneously.
Administer 25 mL of 50% dextrose.
Obtain a blood glucose reading.
The Correct Answer is D
Choice A rationale
While obtaining a full set of vital signs is an important part of assessing a patient’s condition, it should not be the initial action in this case. The symptoms described by the patient suggest hypoglycemia, which requires immediate confirmation and treatment.
Choice B rationale
Administering 1 mg glucagon subcutaneously is not the initial action. Glucagon is used to treat severe hypoglycemia when the patient is unable to take glucose orally. However, the patient’s blood glucose level should be checked first.
Choice C rationale
Administering 25 mL of 50% dextrose is not the initial action. This treatment is used for severe hypoglycemia, but the patient’s blood glucose level should be checked first to confirm hypoglycemia.
Choice D rationale
Obtaining a blood glucose reading is the correct initial action. The symptoms described by the patient suggest hypoglycemia. Checking the blood glucose level will confirm whether the patient is hypoglycemic and needs treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The Trendelenburg position, with the stump supported on three pillows, is not typically recommended following a below-the-knee amputation. This position could increase the risk of contractures.
Choice B rationale
Side lying with the amputated leg flexed is not typically recommended following a below-the- knee amputation. This position could increase the risk of contractures.
Choice C rationale
Lying prone for 24 hours is not typically recommended following a below-the-knee amputation. While some prone positioning may be beneficial to prevent hip flexion contractures, it should not be the only position used.
Choice D rationale
The supine position, with the stump flat on the bed, is often recommended following a below- the-knee amputation. This position helps to prevent contractures and promotes healing.
Correct Answer is B
Explanation
Choice A rationale
Increasing the nighttime insulin glargine dose may exacerbate the Somogyi effect, a phenomenon where the blood sugar level drops too low overnight, causing a rebound high blood sugar level in the morning.
Choice B rationale
Consuming a snack at bedtime can help prevent the blood sugar level from dropping too low overnight, thus preventing the Somogyi effect.
Choice C rationale
Checking the morning cortisol level is not directly related to managing the Somogyi effect.
Choice D rationale
Checking the glucose level at 2 a.m. and 8 a.m. can help identify the Somogyi effect, but it does not prevent it.
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