At 1630 a Type I diabetic client's blood glucose level is 50 mg/dl. The client is alert; however, dinner will not be served until 1715. The nurse's initial action should be to:

monitor the client closely until dinner arrives.

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.

have the client dissolve a small piece of hard candy in their mouth.

Answer and Explanation

The Correct Answer is B

A.   While monitoring is important, doing nothing to address the hypoglycemia is not safe. A blood glucose level of 50 mg/dL is low and requires immediate intervention to prevent more severe hypoglycemic symptoms or complications.
B.   This is a suitable option for treating mild to moderate hypoglycemia. Orange juice is a quick source of carbohydrates and can effectively raise blood glucose levels. Four ounces typically provides enough sugar to help increase the client's blood glucose level before dinner is served.
C.   While this option would also effectively raise blood glucose, it is more complicated than simply having the client drink orange juice. The sugar may take additional time to dissolve, and grape juice may not be readily available. In an acute situation, simplicity and speed are key.
D.   While hard candy can raise blood glucose levels, it may take longer to dissolve and provide sufficient glucose quickly compared to liquid sources like orange juice or grape juice. Additionally, the amount of candy needed may not be clear, making this a less reliable option in an urgent situation.

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Correct Answer is C

Explanation

A. While anxiety can exacerbate feelings of breathlessness, treating anxiety does not address the
underlying issue of respiratory distress. It is important to first stabilize the client’s respiratory condition
before managing anxiety.
B. Auscultating breath sounds can provide valuable information regarding the client’s respiratory status. However, in an emergency situation, immediate interventions to stabilize the client should take precedence over assessments, especially since the vital signs indicate significant distress.

C. Elevating the head of the bed can help improve respiratory effort by allowing better lung expansion and reducing the work of breathing. Given the client’s low oxygen saturation and signs of respiratory distress, this intervention can provide immediate relief and improve oxygenation.
D. While this may be necessary if the client's condition worsens or does not improve, it is not the first action to take. Preparing for mechanical ventilation is a more advanced intervention and should only occur after initial stabilization efforts have been made.

A. 2 to 4 hours. B. 12 to 16 hours. C. 3 to 10 hours. D. 2 to 8 hours.

Correct Answer is A

Explanation

This is the expected peak time for regular insulin. After administration, insulin will generally reach its maximum effectiveness in lowering blood glucose within this timeframe, making it crucial for the client to eat or take carbohydrates to prevent hypoglycemia.

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At 1630 a Type I diabetic client's blood glucose level is 50 mg/dl. The client is alert; however, dinner will not be served until 1715. The nurse's initial action should be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client's insulin dosage is 16 units of regular insulin in the morning. The client should be taught to expect the insulin peak within:

Correct Answer is A

Explanation

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