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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Moist mucous membranes: This is incorrect. In diabetes insipidus, the body loses large amounts of water due to a deficiency of antidiuretic hormone (ADH) or its effects. As a result, the client often experiences dehydration, leading to dry mucous membranes, not moist ones.
B. Bounding peripheral pulses: This is incorrect. While bounding pulses are often seen in conditions like fluid overload or hypervolemia, diabetes insipidus typically causes dehydration due to excessive urination, which would not lead to bounding pulses. The pulses would more likely be weak or thready due to fluid loss.
C. Urine specific gravity 1.002: This is the correct finding. In diabetes insipidus, the kidneys are unable to concentrate urine, resulting in very dilute urine. A urine specific gravity of 1.002 indicates very diluted urine, which is characteristic of diabetes insipidus.
D. Bradycardia: This is incorrect. Bradycardia (slow heart rate) is not typically associated with diabetes insipidus. In fact, tachycardia (increased heart rate) can occur as a compensatory response to dehydration caused by excessive urination in diabetes insipidus.
Correct Answer is B
Explanation
A. Cheyne-Stokes breathing is characterized by periods of deep breathing followed by apnea and is often associated with conditions like heart failure or brain injury, not diabetic ketoacidosis (DKA).
B. Acetone odor to breath is a hallmark sign of diabetic ketoacidosis. The body breaks down fats for energy, producing ketones, which are released in the breath, giving it a fruity or acetone-like odor.
C. A blood glucose level below 40 mg/dL would indicate hypoglycemia, not DKA. In DKA, blood glucose levels are typically elevated (above 250 mg/dL).
D. Malignant hypertension refers to extremely high blood pressure with organ damage, and is not directly related to diabetic ketoacidosis.
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