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 D

Explanation

A. Insulin detemir is a long-acting basal insulin used for maintenance therapy, not for the rapid reduction of blood glucose levels in acute conditions like diabetic ketoacidosis (DKA).
B. NPH insulin is an intermediate-acting insulin used for long-term blood glucose control, but it is not appropriate for immediate treatment of DKA.
C. Insulin glargine is also a long-acting insulin that works over a prolonged period, making it unsuitable for emergency situations like DKA.
D. Regular insulin is the preferred choice for treating diabetic ketoacidosis. It is a short-acting insulin that can rapidly reduce blood glucose levels and is used intravenously for immediate intervention in DKA.

A. Document the amount of drainage. B. Notify the client's provider. C. Obtain a culture of the drainage. D. Check the drainage for glucose.

Correct Answer is D

Explanation

A. While documenting the amount of drainage is important, it is not the most urgent action when clear drainage is observed after a transsphenoidal hypophysectomy.
B. Notifying the provider is important but should not be the first step. The nurse should first assess the nature of the drainage, as it could indicate a serious complication, such as cerebrospinal fluid (CSF) leakage.
C. A culture may be necessary if infection is suspected, but the priority action is to assess whether the drainage is CSF.
D. Checking the drainage for glucose is the most appropriate initial action. Clear drainage from the nasal packing could indicate a CSF leak, which is a complication that can occur after transsphenoidal surgery. CSF contains glucose, so testing for glucose in the drainage will help determine if it is CSF. If glucose is detected, the nurse should immediately notify the provider, as CSF leakage requires prompt intervention.

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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

Correct Answer is D

Explanation

A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?

Correct Answer is D

Explanation

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