At 2:00 AM. the CNA reports that a patient with type 1 diabetes is extremely wet with perspiration, is cool to the touch, and is complaining of hunger. The nurse instructs the CNA to check a capillary blood sugar. The CNA reports the result is 51mg/dL. Which of the following is the BEST nursing action:
notify the night supervisor of the patient's deteriorating condition.
give 4 ounces of orange juice, wait 15 minutes and re-check the capillary blood sugar, followed by 15g of a complex carbohydrate with a protein, such as wheat bread peanut butter.
ambulate the patient in the hall to use up excess glucose with exercise.
give insulin by sliding scale based on glucometer reading.
The Correct Answer is B
A. Notify the night supervisor of the patient's deteriorating condition: While it’s important to keep supervisors informed, hypoglycemia needs to be treated immediately. The priority action is to raise the patient’s blood glucose level, not waiting to notify the supervisor.
B. The patient is experiencing symptoms of hypoglycemia, and the best initial action is to give a fast-acting carbohydrate like orange juice (about 15g of sugar). After 15 minutes, the blood sugar should be rechecked. Following the treatment with a complex carbohydrate and protein helps to maintain blood glucose levels and prevent recurrence of hypoglycemia.
C. Ambulate the patient in the hall to use up excess glucose with exercise: Exercise can lower blood glucose levels, which would be dangerous in a hypoglycemic patient. The priority is to raise the blood sugar rather than use exercise to manage glucose levels.
D. Give insulin by sliding scale based on glucometer reading: The patient’s blood sugar is low (51 mg/dL), which indicates hypoglycemia, not hyperglycemia. Insulin should not be administered in this situation, as it would further decrease the blood glucose levels.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Give the client juice or hard candy immediately: While giving juice or hard candy is an appropriate treatment for hypoglycemia, assessing the blood glucose level first is crucial to confirm that the symptoms are indeed due to low blood sugar.
B. Call the health care provider: While it's important to notify the healthcare provider if the situation worsens or if there's a concern about the client's safety, the first priority is to assess the blood glucose level and take immediate action to treat the hypoglycemia.
C. Have the client lie down and see if symptoms subside: Lying down does not address the underlying cause of hypoglycemia. The client may need glucose to raise their blood sugar levels, so this is not the most effective first action.
D. Assess the blood glucose level, and administer glucose in the most appropriate form: Assessing the blood glucose level will confirm whether the symptoms are indeed due to hypoglycemia, and then the nurse can proceed with administering glucose in the most appropriate form (such as oral glucose, juice, or glucose tablets).
Correct Answer is B
Explanation
A. Characterized mainly by insulin resistance: Insulin resistance is more characteristic of type 2 diabetes, not type 1 diabetes. In type 1 diabetes, the body is unable to produce insulin due to the autoimmune destruction of pancreatic beta cells.
B. Characterized mainly by insulin deficiency: Type 1 diabetes is caused by insulin deficiency due to the body's inability to produce insulin, leading to high blood sugar levels. This is a life-long condition that requires insulin replacement for proper blood glucose control.
C. Best managed through diet, exercise, and oral medication: Type 1 diabetes cannot be managed with oral medication alone. It requires insulin injections or an insulin pump in addition to diet and exercise to control blood glucose levels.
D. Can be prevented by proper nutrition and monitoring blood glucose levels: Type 1 diabetes is an autoimmune disease and cannot be prevented through nutrition or blood glucose monitoring. Prevention strategies are more applicable to type 2 diabetes.
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