The client received ten (12) units of regular insulin at 08:00. At 11:30 the unlicensed assistant personnel (UAP) tells the nurse the client has a headache and is really acting funny. Which intervention should the registered nurse implement first?

Instruct the UAP to obtain a blood glucose level

Go to the client's room and assess the client for hypoglycemia

Have the client drink 8 ounces of orange juice

Prepare to administer one ampule 50% dextrose intravenously

Answer and Explanation

The Correct Answer is B

A. Instructing the UAP to obtain a blood glucose level could be useful, but the nurse should prioritize assessing the client directly.
B. Assessing the client is the first step to confirm hypoglycemia and determine the severity, allowing for appropriate intervention.
C. Administering orange juice may be appropriate after confirming hypoglycemia, but an assessment should be performed first.
D. Administering dextrose is a severe intervention used when symptoms are extreme; assessment should occur first.

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Correct Answer is D

Explanation

A. Urine-specific gravity provides information on the kidney's ability to concentrate urine but is not the most direct measure of renal function.
B. Blood urea nitrogen (BUN) can indicate kidney function but is influenced by factors other than kidney health, such as hydration status and protein intake.
C. Serum sodium levels are not a specific indicator of renal function and can vary based on many factors unrelated to kidney health.
D. Serum creatinine is the best indicator of renal function, as it is produced from muscle metabolism and cleared by the kidneys; elevated levels indicate decreased renal function.

A. "Do you need to increase your insulin dosage when you are stressed?" B. "Have you noticed any painful new ulcerations or sores on your feet?" C. "Have you seen any skin changes?" D. "Do you feel bloated after eating?"

Correct Answer is D

Explanation

A. This question assesses for glucose management under stress but does not specifically target autonomic neuropathy.
B. Painful ulcerations relate more to peripheral neuropathy rather than autonomic neuropathy.
C. Skin changes could be a result of diabetes but do not directly assess autonomic neuropathy.
D. Autonomic neuropathy can affect digestion, leading to symptoms such as bloating due to delayed gastric emptying (gastroparesis).

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The client received ten (12) units of regular insulin at 08:00. At 11:30 the unlicensed assistant personnel (UAP) tells the nurse the client has a headache and is really acting funny. Which intervention should the registered nurse implement first?

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