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. Checking urine for ketones is generally recommended when blood glucose is consistently high, but once daily may not be sufficient during illness or hyperglycemic episodes.
B. Monitoring blood glucose every 4 hours during illness helps manage potential fluctuations and prevent diabetic ketoacidosis, making this statement correct.
C. A pre-meal blood glucose of 120 mg/dL is within the acceptable range, so notifying the provider is unnecessary.
D. Checking blood glucose every 5 minutes is excessive and not standard practice, even if feeling lightheaded.
Correct Answer is A
Explanation
A. Shakiness is a classic symptom of hypoglycemia due to adrenaline release as the body responds to low glucose levels.
B. Decreased appetite is not typical of hypoglycemia; in fact, hunger may increase as the body signals the need for energy.
C. Increased thirst is a symptom of hyperglycemia, not hypoglycemia.
D. Skin is typically cool and clammy during hypoglycemia, not warm and moist.
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