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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Hypoglycemia, or low blood sugar, can occur after insulin administration. However, the onset of hypoglycemia is not immediate. Insulin aspart, a rapid-acting insulin, has a peak action time of approximately 1-3 hours after administration. Therefore, assessing the patient for signs and symptoms of hypoglycemia at 0800, one hour after administration, may be too early.

Choice B rationale

Assessing the patient for signs and symptoms of hypoglycemia at 0730, 30 minutes after insulin administration, is too early. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.

Choice C rationale

Assessing the patient for signs and symptoms of hypoglycemia at 1130, four and a half hours after insulin administration, may be too late. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.

Choice D rationale

Assessing the patient for signs and symptoms of hypoglycemia at 1000, three hours after insulin administration, is within the peak action time of insulin aspart. Therefore, this is the most appropriate time to start assessing the patient for signs and symptoms of hypoglycemia.

A. Obtain a pair of heavy-duty gloves to wear for cold exposures. B. Refrain from going outdoors during the winter months. C. Raise the hands above the head to relieve the spasms. D. Use small rubber balls to exercise your hands and fingers daily.

Correct Answer is A

Explanation

Choice A rationale

Raynaud’s disease is a condition that affects blood flow to the extremities, including the fingers and toes, in response to cold temperatures or stress. Wearing heavy-duty gloves during cold exposures can help to keep the hands warm and reduce the risk of a Raynaud’s attack.

Choice B rationale

While avoiding cold temperatures can help to prevent Raynaud’s attacks, it is not always practical or possible for individuals to refrain from going outdoors during the winter months.

Choice C rationale

Raising the hands above the head is not typically recommended to relieve spasms associated with Raynaud’s disease.

Choice D rationale

Using small rubber balls to exercise the hands and fingers daily may be beneficial for some individuals with Raynaud’s disease, but it is not typically the primary recommendation for managing this condition.

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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?

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A client diagnosed with Raynaud’s disease is experiencing severe pain and spasms in the fingers and toes of their hands. What advice should the nurse include in the discharge instructions for this client?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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