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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Moderate sedation (also called conscious sedation) involves the administration of medications (e.g., midazolam, fentanyl, or propofol) to reduce anxiety, pain, and awareness during procedures, while allowing the patient to:

Remain awake but relaxed
Respond to verbal commands
Maintain their own airway without the need for intubation

It is commonly used for minor surgical procedures, endoscopies, and dental procedures.

A. 2+ pedal edema bilaterally B. Blood pressure at 107/82 C. Urine output of 460 mL in 24 hours D. Disorientation

Correct Answer is D

Explanation

A. 2+ pedal edema bilaterally:
While 2+ pedal edema (a mild level of swelling in the feet and ankles) is concerning, it is not an immediate emergency in the context of hyponatremia. Edema can be seen in various conditions, including fluid retention associated with hyponatremia, but it does not require urgent intervention unless it is severe or worsening. This finding would warrant monitoring but does not require immediate action.

B. Blood pressure at 107/82:
A blood pressure reading of 107/82 mmHg is within normal limits, although on the lower end of the spectrum. This is not a concerning finding in this case and does not suggest a need for immediate intervention. The nurse should continue to monitor the client, but this blood pressure reading alone is not an emergency.
C. Urine output of 460 mL in 24 hours:
A urine output of 460 mL in 24 hours is low, indicating oliguria (decreased urine output), which can occur in cases of hyponatremia due to fluid retention. However, unless the urine output is worsening or associated with other signs of acute kidney injury or severe fluid overload, this finding alone does not require immediate intervention. It is something that should be monitored and further investigated.

D. Disorientation:
Disorientation in the elderly client with hyponatremia is a critical finding that requires immediate intervention. Hyponatremia can lead to cerebral edema (brain swelling), which results in altered mental status, including confusion, disorientation, or seizures. These symptoms indicate that the hyponatremia may be severe enough to affect neurological function and requires prompt correction to avoid further complications, such as coma or permanent brain damage. Immediate intervention to address the underlying cause of the hyponatremia and restore sodium balance is crucial.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a student on moderate/conscious sedation. Which of the following is a correct statement about moderate sedation?

Correct Answer is D

Explanation

The nurse is assessing an elderly client admitted for hyponatremia. Which of the following findings requires immediate intervention?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide?

In which client would a prescription of valproic acid for seizure disorder be contraindicated?

A nurse is preparing to give routine medications to a client with a history of hypertension. The nurse recognizes the need to assess the clients blood pressure before and after administering which of the following medications?

A client is tested for human immunodeficiency virus (HIV) infection with an enzyme- linked immunosorbent assay (ELISA), and the test result & positive. What would the nurse tell the client?

The nurse is caring who presented with unstable angina. Before giving the client, a dose of sublingual nitroglycerin, which action should the nurse take?

A client who following prescribed multiple medications for recurring urinary tract infections tells the nurse that her urine has turned red-orange. Which of the following prescribed medications does the nurse suspect is responsible for this change?

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?

The nurse is caring for a client and witnesses them begin to have tonic-cionic.seizure. The client has a patent peripheral IV medications would the nurse most likely administer seizure activity