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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["7"]
Explanation
Given:
Desired dose: Amoxicillin 350 mg PO
Available concentration: Amoxicillin 250 mg/5 ml
To find:
Volume to administer (in ml)
Step 1: Set up the proportion
We can use the following proportion to solve the problem:
(Desired dose) / (Available concentration) = Volume to administer
Step 2: Substitute the values
Plugging in the given values, we get:
(350 mg) / (250 mg/5 ml) = Volume to administer
Step 3: Simplify
To simplify, we can invert the denominator and multiply:
(350 mg) x (5 ml / 250 mg) = Volume to administer
The "mg" units cancel out, leaving us with:
(350 x 5 ml) / 250 = Volume to administer
Step 4: Calculate
Performing the multiplication and division, we get:
1750 ml / 250 = Volume to administer
1 ml = Volume to administer
Correct Answer is ["A","C","D"]
Explanation
The correct answers are:
A. You may start taking warfarin while still on heparin when you are getting ready to be discharged home.
- Warfarin takes several days to reach therapeutic levels, so patients often overlap with heparin until the INR (International Normalized Ratio) reaches the target range (typically 2.0-3.0 for most conditions).
C. Use a soft-bristled toothbrush and avoid brushing too aggressively.
- Warfarin increases the risk of bleeding, so using a soft toothbrush helps prevent gum bleeding.
D. You should replace straight razors with an electric shaver to avoid cuts.
- Since warfarin thins the blood, small cuts can lead to excessive bleeding. An electric shaver reduces the risk of accidental cuts.
B. You will need to have your aPTT monitored frequently while on Warfarin. (Incorrect)
- Warfarin is monitored using INR and PT (Prothrombin Time), not aPTT.
- aPTT (Activated Partial Thromboplastin Time) is used to monitor heparin therapy, not warfarin.
E. Increase foods high in vitamin K like dark green leafy vegetables while taking Warfarin. (Incorrect)
- Vitamin K counteracts warfarin's effects, so patients should keep their vitamin K intake consistent rather than increasing it.
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