After giving 6 oz of orange juice to a patient with hypoglycemia, the nurse finds that the patient's blood glucose level is 65 mg/dl. Which nursing intervention would be the most appropriate in this situation?

Giving an additional 15 g of carbohydrate

Giving 25 to 50 ml of 50% glucose IV

Administering 1 mg IM glucagon

Administering 5% to 10% dextrose infusion

Answer and Explanation

The Correct Answer is A

A. After administering a carbohydrate source (e.g., 6 oz of orange juice), the nurse should reassess the patient's blood glucose level. If the glucose is still below the target range (typically above 70 mg/dL), the next step is to give an additional 15 grams of carbohydrate to raise the blood sugar. This is a standard approach for mild to moderate hypoglycemia.
B. Giving 25 to 50 ml of 50% glucose IV is typically reserved for patients who are severely hypoglycemic and unable to swallow or are unresponsive. This method is appropriate when the patient cannot take oral glucose, but the client in this scenario is still conscious.
C. Administering 1 mg IM glucagon is used when a patient is unable to ingest glucose orally and is unresponsive or vomiting. It stimulates the liver to release stored glucose, but this is not necessary in a conscious patient who can swallow.
D. Administering a 5% to 10% dextrose infusion is typically used in more severe cases of hypoglycemia, especially when IV access is established, and the patient is unable to take oral glucose. This would not be necessary for a patient who can safely swallow.

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Correct Answer is C

Explanation

A. Furosemide is a diuretic that is used to reduce fluid overload and manage conditions like heart failure or kidney disease. It is not indicated in anaphylaxis.
B. Methylprednisolone is a corticosteroid used for its anti-inflammatory properties and can be used in anaphylaxis to reduce inflammation and prevent delayed reactions. However, it is not the first-line treatment in acute anaphylactic shock.
C. Epinephrine is the first-line treatment for anaphylactic shock. It works by rapidly reversing the effects of anaphylaxis, such as bronchoconstriction, vasodilation, and edema, by stimulating alpha and beta receptors. Epinephrine should be administered as soon as anaphylaxis is suspected to stabilize the patient’s condition.
D. Dobutamine is a medication used to manage shock by increasing cardiac output, but it is not used in the management of anaphylactic shock. The priority is epinephrine to reverse the anaphylactic response.

A. Stop the infusion. B. Elevate the head of the bed. C. Auscultate the client's breath sounds. D. Call the client's provider.

Correct Answer is A

Explanation

A. The client is likely experiencing an allergic reaction to penicillin, such as anaphylaxis, which can cause symptoms like itching, dizziness, and difficulty breathing. The first step is to stop the infusion immediately to prevent further exposure to the allergen.
B. Elevating the head of the bed might be helpful if the client is experiencing respiratory distress, but stopping the infusion is the priority action.
C. Auscultating the client's breath sounds may be useful later to assess the severity of respiratory distress, but it is not the first action in an acute allergic reaction.
D. Calling the provider is important, but the immediate priority is stopping the infusion to prevent further harm from the allergic reaction.

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After giving 6 oz of orange juice to a patient with hypoglycemia, the nurse finds that the patient's blood glucose level is 65 mg/dl. Which nursing intervention would be the most appropriate in this situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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