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

Glucagon IM

Regular insulin IV infusion

Potassium laboratory monitoring

IV fluid replacement

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is A

Explanation

Midazolam is a benzodiazepine commonly used for the emergency treatment of seizures, including tonic-clonic (grand mal) seizures. It works by enhancing GABA activity in the brain, helping to stop seizure activity quickly. It can be administered intravenously (IV), intramuscularly (IM), or intranasally in emergencies.

A. Have the client lay prone for 30 minutes. 3-4 times a day B. Continue using the limb prosthesis even if skin appear irritated C. Withhold medication for phantom limb pain as it isn't real pain D. Keep the residual limb elevated to achieve as close to as close to 90-degree hip flexion as possible

Correct Answer is A

Explanation

A. Have the client lay prone for 30 minutes. 3-4 times a day:
This statement is correct. Lying prone (on the stomach) for 30 minutes several times a day helps to prevent hip flexion contractures, which are common complications after an above-the-knee amputation. By lying prone, the residual limb is stretched and the hip joint is kept in an extended position, which helps maintain proper alignment and reduces the risk of contractures. This is a key part of postoperative care to promote optimal positioning and rehabilitation.

B. Continue using the limb prosthesis even if the skin appears irritated:
This statement is incorrect. If the skin becomes irritated or damaged, the prosthesis should not be used until the skin has healed. Continued use of the prosthesis in the presence of skin irritation can cause further damage, leading to ulcers or infections. It is essential to regularly check the residual limb for irritation, redness, or sores and adjust the prosthesis as needed. If irritation is present, the prosthesis should be removed, and appropriate skin care should be provided.

C. Withhold medication for phantom limb pain as it isn't real pain:
This statement is incorrect. Phantom limb pain is real and a common experience for individuals after an amputation. It occurs when the brain perceives pain sensations in the area where the limb used to be, even though the limb is no longer there. Phantom limb pain is often treated with pain medications, including analgesics, anticonvulsants, or antidepressants, and should not be withheld. Proper management of phantom limb pain is important for the client's comfort and overall well-being.

D. Keep the residual limb elevated to achieve as close to 90-degree hip flexion as possible:
This statement is incorrect. While it is important to elevate the residual limb after surgery to reduce swelling, it should not be elevated to the point where the hip joint is flexed to 90 degrees. Elevating the limb too much or for prolonged periods can increase the risk of developing a hip flexion contracture, which would impair mobility. The residual limb should be elevated slightly, but the hip joint should not be excessively flexed. Ideally, the limb should be positioned in a neutral or extended position when elevated.

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