A patient with type 1 diabetes mellitus has been prescribed a glucagon emergency kit for home use.

When should the nurse instruct the patient and family that glucagon needs to be administered?

Before meals to prevent hyperglycemia.

When signs of severe hypoglycemia occur.

When unable to eat during sick days.

At the onset of signs of diabetic ketoacidosis.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Glucagon should not be administered before meals to prevent hyperglycemia. Glucagon is a hormone that raises blood glucose levels and is used to treat severe hypoglycemia. It is not intended to prevent hyperglycemia.

Choice B rationale

Glucagon should be administered when signs of severe hypoglycemia occur. Hypoglycemia, or low blood sugar, can cause symptoms such as confusion, dizziness, hunger, and shakiness. If left untreated, severe hypoglycemia can lead to unconsciousness or seizures.

Choice C rationale

Glucagon should not be administered when unable to eat during sick days. While it’s important to maintain blood glucose levels during illness, glucagon is specifically used for severe hypoglycemia.

Choice D rationale

Glucagon should not be administered at the onset of signs of diabetic ketoacidosis. Diabetic ketoacidosis is a serious condition that requires immediate medical attention. Glucagon is not a treatment for this condition.

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Correct Answer is D

Explanation

Choice A rationale

While a coronary artery bypass procedure is a significant event in a patient’s medical history, it occurred in 1995, which is quite some time ago. Therefore, it may not be the most significant piece of data when planning this client’s care, given their current signs and symptoms.

Choice B rationale

A colonoscopy performed for routine screening six months ago is unlikely to be related to the client’s current symptoms of nausea, vomiting, and anorexia. Therefore, this choice is not the most significant piece of data when planning this client’s care.

Choice C rationale

Depression following the death of a spouse can significantly impact a person’s mental health. However, this event occurred in 1999, and while it may contribute to the client’s overall health status, it is not likely to be the most significant piece of data for planning care based on the client’s current symptoms.

Choice D rationale

The client has been taking digoxin and furosemide daily since 19962. Both of these medications are used to treat heart conditions. Digoxin strengthens the heart’s contractions, while furosemide is a diuretic that helps reduce fluid buildup. Given the client’s symptoms of nausea, vomiting, and anorexia, and their diagnosis of heart failure, this information is crucial. These symptoms could indicate a worsening of heart failure or side effects of the medication, which would significantly influence the plan of care.

A. Advise the patient to move slowly and cautiously when getting up and walking. B. Evaluate the patient’s muscle strength every 4 hours. C. Monitor the patient’s intake and output every 8 hours. D. Ensure the patient understands to stop taking baclofen before using other antispasmodics.

Correct Answer is A

Explanation

Choice A rationale

Baclofen is a muscle relaxant used to treat muscle symptoms caused by multiple sclerosis (MS), including spasm, pain, and stiffness. It acts on the central nervous system to relieve spasticity, improving muscle movement and relieving pain from spasticity. One of the common side effects of Baclofen is drowsiness, dizziness, and weakness. Therefore, advising the patient to move slowly and cautiously when getting up and walking is an important nursing intervention to prevent falls and injuries.

Choice B rationale

While evaluating the patient’s muscle strength every 4 hours can provide valuable information about the patient’s response to treatment, it is not the most critical intervention in this context. Baclofen’s primary effect is to relieve spasticity, not necessarily to increase muscle strength.

Choice C rationale

Monitoring the patient’s intake and output every 8 hours is a standard nursing intervention for many patients, but it is not specifically related to the administration of baclofen.

Choice D rationale

While it’s important for patients to understand their medication regimen, including when to stop taking certain medications, baclofen should not be stopped abruptly. Abrupt discontinuation has resulted in serious adverse reactions including death. Therefore, ensuring the patient understands to stop taking baclofen before using other antispasmodics is not the correct intervention.

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A patient with type 1 diabetes mellitus has been prescribed a glucagon emergency kit for home use.When should the nurse instruct the patient and family that glucagon needs to be administered?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?

Correct Answer is D

Explanation

The nurse is administering the muscle relaxant baclofen orally to a patient diagnosed with multiple sclerosis. What intervention should the nurse implement?

Correct Answer is A

Explanation

The nurse is administering sodium polystyrene sulfonate to a client with acute kidney injury (AKI). Which laboratory finding indicates that the medication has been effective?

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A patient with open-angle glaucoma asks the nurse about the duration of use for the prescribed eye drops. What is the nurse’s accurate response?

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A patient with type 1 diabetes mellitus has been prescribed a glucagon emergency kit for home use.

When should the nurse instruct the patient and family that glucagon needs to be administered?