The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse’s priority for planning care?

RBCs 4.3mEq/L

Potassium 4.8 mEq/L

Hemoglobin of 9g/dl

Sodium 137 mEq/L

Answer and Explanation

The Correct Answer is C

A) RBCs 4.3 million/µL:
While a low RBC count can indicate anemia, the specific value provided here is not suggestive of anemia, and it does not explain the patient's symptoms of fatigue, weakness, and dizziness as clearly as a low hemoglobin would.

B) Potassium 4.8 mEq/L:
This result is not concerning and does not directly relate to the patient's reported symptoms of pallor, fatigue, and dizziness. Therefore, this lab result does not take priority in planning care at this time.

C) Hemoglobin of 9 g/dl:
This result is consistent with anemia, which is a likely cause of the patient’s symptoms of fatigue, weakness, dizziness, and pallor. Anemia can lead to decreased oxygen delivery to tissues, explaining the symptoms the patient is experiencing. The priority action for the nurse should be to address the underlying cause of anemia and manage it to improve the patient’s oxygenation and overall condition.

D) Sodium 137 mEq/L:
Although sodium imbalances can cause neurological symptoms such as confusion or lethargy, the patient’s reported symptoms of pallor, fatigue, and dizziness are more likely related to anemia. Sodium is not the most urgent concern for this patient at the moment.

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Correct Answer is A

Explanation

A. Glucagon IM:
Glucagon is used to treat hypoglycemia (low blood sugar), not hyperglycemia. It is typically administered intramuscularly in cases of severe hypoglycemia to rapidly raise blood glucose levels. In acute hyperglycemia, the blood glucose is already elevated, so glucagon is not appropriate. The correct treatment for hyperglycemia includes insulin administration, fluid replacement, and monitoring of electrolytes.

B. Regular insulin IV infusion:
In acute hyperglycemia, particularly in cases of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), regular insulin is commonly administered intravenously to reduce blood glucose levels. It acts rapidly to lower blood glucose, and the dose can be adjusted based on the client's response. Therefore, this is an expected intervention in the management of acute hyperglycemia.

C. Potassium laboratory monitoring:
In acute hyperglycemia, particularly during insulin administration, potassium levels should be closely monitored. Insulin can drive potassium into cells, potentially leading to hypokalemia (low potassium levels). Since hyperglycemia treatment can alter electrolyte balance, potassium levels need to be frequently checked to avoid complications like arrhythmias or muscle weakness. This is an important intervention in managing hyperglycemia.

D. IV fluid replacement:
IV fluid replacement is a crucial part of managing acute hyperglycemia, particularly in conditions like DKA and HHS. These conditions cause dehydration due to osmotic diuresis, and fluid replacement helps to restore normal hydration status and support renal function. The nurse would expect IV fluid administration to correct electrolyte imbalances and improve circulatory volume.

A. Rapid loss of consciousness B. Excessive urination C. Lack of appetite D. Excessive thirst E. Slow shallow respirations.

Correct Answer is ["B","D"]

Explanation

A. Rapid loss of consciousness:
Rapid loss of consciousness is not typically a sign of hyperglycemia in type 1 diabetes. While hyperglycemia can lead to diabetic ketoacidosis (DKA) if it is severe and prolonged, which can cause confusion or stupor, rapid loss of consciousness is more often associated with severe hypoglycemia (low blood sugar), not hyperglycemia. Therefore, this is not a typical symptom of hyperglycemia in type 1 diabetes.

B. Excessive urination:
This is a correct sign of hyperglycemia. When blood sugar levels rise, the kidneys try to filter out the excess glucose, which leads to increased urination (polyuria). The kidneys cannot reabsorb all the glucose, and the excess glucose in the urine draws water with it, leading to more frequent urination.

C. Lack of appetite:
A lack of appetite is not typically associated with hyperglycemia. In fact, people with hyperglycemia or high blood sugar are often more likely to experience increased hunger (polyphagia) due to insulin resistance or the body’s inability to utilize glucose properly. A lack of appetite is more common in hypoglycemia (low blood sugar) or in conditions like diabetic ketoacidosis (DKA), where nausea and vomiting are also common. Therefore, this is not a sign of hyperglycemia.

D. Excessive thirst:
This is a correct sign of hyperglycemia. High blood sugar leads to excessive urination, which in turn causes dehydration. As a result, individuals with hyperglycemia may experience polydipsia (excessive thirst) as the body tries to compensate for the fluid loss.

E. Slow shallow respirations:
Slow, shallow respirations are typically a sign of respiratory depression and are more likely to be associated with hypoventilation or complications like diabetic ketoacidosis (DKA), rather than hyperglycemia alone. In DKA, a common complication of poorly controlled type 1 diabetes, respirations may become deep and rapid (Kussmaul respirations) in an attempt to blow off excess CO2 and correct the acidosis. Therefore, slow, shallow respirations are not a typical sign of hyperglycemia.

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The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse’s priority for planning care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client experiencing acute hyperglycemia. The nurse would expect all of the following interventions except which?

Correct Answer is A

Explanation

The nurse recognizes which of the following as signs and symptoms of hyperglycemia type I diabetes mellitus? Select all that apply,

Correct Answer is ["B","D"]

Explanation

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