An older adult client, who has type 2 diabetes mellitus (DM), is at an adult daycare center. The client becomes diaphoretic, confused, and unable to interact with the other daycare participants. The client tells the practical nurse (PN), "I just don't feel right." Which initial action should the PN take?
Give 4 oz (120 mL) of apple juice.
Administer glucagon 0.5 mg IM.
Assess temperature.
Evaluate deep tendon reflexes.
The Correct Answer is A
A. Give 4 oz (120 mL) of apple juice:
Diaphoresis, confusion, and “not feeling right” indicate hypoglycemia. Rapid-acting carbohydrates should be given immediately if the client can swallow.
B. Administer glucagon 0.5 mg IM:
Used if the client is unconscious or unable to swallow safely.
C. Assess temperature:
Does not address the immediate risk of hypoglycemia.
D. Evaluate deep tendon reflexes:
Not relevant to urgent management of suspected hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. Removes the water pitcher from room of client on fluid restriction:
Correct practice for fluid restriction; no guidance needed.
B. Uses client's same finger when obtaining a blood drop for glucometer:
Repeated use can cause trauma/infection; rotate sites.
C. Applies disposable gown and mask as part of standard precautions:
Standard precautions require PPE only when risk of exposure exists, not routinely.
D. Maintains Fowler's position for a client with breathing difficulty:
Correct practice; supports lung expansion.
E. Positions bed in highest position before leaving all client rooms:
Unsafe; bed should be left in lowest position to prevent falls.
Correct Answer is A
Explanation
A. Contact the healthcare provider to reschedule the surgery:
A discrepancy between the consent form and surgical site is a serious safety concern. The surgery must be halted until the error is corrected, even if pre-op medication has been given. This prevents wrong-site surgery.
B. Obtain verbal consent from the client's nearest relative or significant other:
Consent must come directly from the patient if they are competent. Verbal consent from a relative is not valid unless the patient is unable to consent.
C. Cross out the error and initial the form to ensure the correct surgery:
The consent form must be corrected and re-signed by the client and provider, not altered by the nurse alone.
D. Transport the client to the surgery suite since medications were administered:
Proceeding with surgery despite a site discrepancy risks harm and violates patient safety protocols.
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