On initial nursing rounds, the diabetic client reports "not feeling well." Later, the nurse finds the client to be diaphoretic and in a stuporous state. What is the immediate action taken by the nurse?

Obtain a glucometer reading.

Administer fruit juice.

Start an IV of dextrose.

Call the physician.

Answer and Explanation

The Correct Answer is A

choice A, Obtain a glucometer reading. The immediate action taken by the nurse is to obtain a glucometer reading to determine the client's blood glucose level. The client's symptoms are suggestive of hypoglycemia, a condition that can lead to coma and seizures if left untreated. Administering fruit juice or starting an IV of dextrose without first checking the client's blood glucose level can worsen the condition if the client's blood glucose is high. The physician should be notified if the client's blood glucose level is critically low or high and if the client's condition does not improve after treatment.
B.   Administering fruit juice can worsen the condition if the client's blood glucose is high.
C.   Starting an IV of dextrose can worsen the condition if the client's blood glucose is high.
D.   Calling the physician is not the immediate action, as the client needs urgent treatment.

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Correct Answer is A

Explanation

Painless hematuria. Painless hematuria, the presence of blood in the urine without any accompanying pain, is the most common initial symptom of a malignant tumor of the bladder. Frequency, choice B, urinary retention, choice C, and fever, choice D, may also be associated with bladder cancer but are not typically the initial symptoms.

A. Administer with low-dose aspirin to prevent clot formation. B. Administer immediately after dialysis. C. Monitor complete blood count prior to dose. D. Schedule injection on nondialysis day.

Correct Answer is D

Explanation

Schedule injection on a nondialysis day. Epoetin is a medication used to stimulate the production of red blood cells. It is important to administer the medication on the day that the client is not receiving dialysis to prevent the medication from being removed from the bloodstream during the dialysis process.

Administering epoetin immediately after dialysis, choice B may result in decreased effectiveness.

Administering with low-dose aspirin, choice A, is not a standard recommendation for the administration of epoetin.

Monitoring the complete blood count prior to the dose, choice C is not the most important consideration when administering epoetin.

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On initial nursing rounds, the diabetic client reports "not feeling well." Later, the nurse finds the client to be diaphoretic and in a stuporous state. What is the immediate action taken by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the history along with physical examination of a client with a suspected malignant tumor of the bladder. Which finding would the nurse identify as the most common initial symptom?

Correct Answer is A

Explanation

The hemodialysis client is scheduled to receive weekly injections of epoetin. Which is the most important consideration to be taken by the nurse in the administration of this medication?

Correct Answer is D

Explanation

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