A Type 1 diabetic client’s blood glucose level is 50 mg/dL at 16:30. The client is alert; however, dinner will not be served until 17:15. What should be the nurse’s initial action?
Have the client drink 4 oz. of orange juice
Give the client 3 tbsp.
of sugar dissolved in 4 oz. of grape juice to drink
Monitor the client closely until dinner arrives
The Correct Answer is A
Step 1 is to understand that a blood glucose level of 50 mg/dL is considered hypoglycemic. Immediate treatment is necessary to raise the blood glucose level.
Step 2 is to follow the 15-15 rule for treating hypoglycemia, which recommends consuming 15 grams of carbohydrates and then checking blood glucose levels after 15 minutes. Four ounces of orange juice contains about 15 grams of carbohydrates and can quickly raise blood glucose levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.
Choice B rationale
Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.
Choice C rationale
Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.
Choice D rationale
Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.
Correct Answer is C
Explanation
Choice A rationale
Monitoring the peak level of the antibiotic is important, but it is not the priority nursing action. Peak levels are typically drawn after the drug has been administered and are used to assess whether the dosage is sufficient.
Choice B rationale
Assessing the client’s vital signs is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.
Choice C rationale
Obtaining a serum trough level is the priority nursing action. Trough levels are drawn just before the next dose of the drug is due and are used to assess whether the dosage is safe.
Choice D rationale
Asking the client about drug allergies is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.