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
While it’s important for clients to understand their medications, not having received proper education on this medication is not a reason to withhold cefazolin.
Choice B rationale
Completing a full course of an aminoglycoside antibiotic does not contraindicate the use of cefazolin.
Choice C rationale
Being afebrile does not contraindicate the use of cefazolin. Antibiotics are used to treat bacterial infections, not just to reduce fever.
Choice D rationale
A prior anaphylactic reaction to penicillin is a contraindication for administering cefazolin. Cefazolin is a cephalosporin, and there is a risk of cross-reactivity and potential allergic reaction in clients who have a history of severe penicillin allergy.
Correct Answer is C
Explanation
Choice A rationale
While a past medical history of myocardial infarction does increase the risk of deep vein thrombosis (DVT), it is not the highest risk factor among the options provided. Other factors such as immobility, surgery, and certain medical conditions can pose a higher risk.
Choice B rationale
Postoperative patients, such as those who have had a laparoscopic knee replacement, are at an increased risk for DVT due to periods of immobility and changes in blood flow and clotting.
However, the risk is not as high as in patients who have undergone major open abdominal surgery.
Choice C rationale
Patients who have undergone major open abdominal surgery are at the highest risk for the development of DVT among the options provided. The surgery itself, along with the postoperative period of immobility, significantly increases the risk of DVT34567.
Choice D rationale
While peptic ulcers can be associated with certain risk factors for DVT, such as age and immobility due to pain, they do not pose as high a risk as major open abdominal surgery.
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