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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Giving carbohydrates at 3:00 AM might prevent hypoglycemia temporarily but does not address the underlying issue.
B. Having a snack at bedtime helps prevent nighttime hypoglycemia, which can lead to rebound hyperglycemia, known as the Somogyi effect.
C. Increasing the insulin dose could exacerbate nocturnal hypoglycemia, worsening the Somogyi effect.
D. Doing nothing is inappropriate as the low 2:00 AM glucose level is a sign of the Somogyi effect.
Correct Answer is ["A","B","D","E"]
Explanation
A. Patency of the drainage tubing is crucial to prevent blockage and maintain continuous flow.
B. Bright red urine or large clots could indicate bleeding, requiring immediate notification of the surgeon.
C. The amount of irrigation fluid is usually subtracted from the total output to determine true urine output, not added.
D. Using sterile technique helps prevent infection in a postoperative patient.
E. A continual urge to void could indicate bladder spasms or improper catheter placement, and the surgeon should be contacted.
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