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
NSAIDs such as ibuprofen are commonly used to manage pain and inflammation. However, they are not typically the first choice for treating phantom limb pain. Phantom limb pain is a complex condition that is thought to involve both peripheral and central mechanisms.
Choice B rationale
Antipyretics such as acetaminophen are used to reduce fever and relieve mild to moderate pain. However, they are not typically used as the primary treatment for phantom limb pain. This type of pain is often resistant to common analgesics, including acetaminophen.
Choice C rationale
Narcotic analgesics such as codeine can be used to manage severe pain. However, they are not typically the first choice for treating phantom limb pain due to the risk of dependency and the fact that this type of pain often does not respond well to opioids.
Choice D rationale
Anticonvulsants such as gabapentin are often used to manage neuropathic pain, including phantom limb pain. Gabapentin works by stabilizing electrical activity in the nervous system and altering the way the nerves send messages to the brain.
Correct Answer is C
Explanation
Choice A rationale
Injecting the insulin syringe at a 90-degree angle is a technique used to ensure that the insulin is delivered into the subcutaneous tissue. However, this does not specifically prevent lipodystrophy.
Choice B rationale
Avoiding the deltoid when injecting insulin is not typically a recommendation for preventing lipodystrophy. Insulin is usually injected into the fatty tissue just under the skin in the abdomen, thighs, buttocks, or upper arms.
Choice C rationale
Rotating injection sites correctly is a key strategy for preventing lipodystrophy. Lipodystrophy refers to abnormal changes in the fat tissue under the skin and can be caused by repeatedly injecting insulin into the same spot.
Choice D rationale
Massaging the injection site is not typically recommended as it can cause the insulin to be absorbed too quickly.
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