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.
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Related Questions
Correct Answer is D
Explanation
A. Low back pain is a symptom that may indicate pyelonephritis but is not specific to older adults.
B. Incontinence can occur in UTIs but is common in older adults for various reasons and is not specific to a UTI.
C. Urinary retention is not a distinguishing feature of UTI in older adults.
D. Confusion or altered mental status is a common sign of UTI in older adults, often the primary symptom due to age-related changes in cognition.
Correct Answer is C
Explanation
A. UTIs typically start as an ascending infection from the urethra into the bladder, not descending.
B. UTIs, especially cystitis, are generally localized infections that do not stem from infections elsewhere in the body.
C. Urinary stasis (incomplete emptying of the bladder) can lead to bacterial growth, which is a common cause of cystitis.
D. While congenital strictures can predispose to infections by causing urinary stasis, they are not the primary cause in most cases of cystitis.
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