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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client should report to an urgent care for potential hypokalemia:
While ACE inhibitors like Captopril can increase potassium levels (hyperkalemia) due to their effects on the renin-angiotensin-aldosterone system, they are not typically associated with hypokalemia. The client's complaint of a dry cough is a well-known side effect of ACE inhibitors, not an indication of low potassium levels. Therefore, the recommendation to seek urgent care for hypokalemia is not appropriate in this case.
B. The client should immediately use an epinephrine auto-injector (Epi-Pen) and call 9-1-1:
The use of an epinephrine auto-injector is specifically indicated for severe allergic reactions (anaphylaxis), which typically present with symptoms such as difficulty breathing, swelling of the throat, or anaphylactic shock. A chronic dry cough associated with the use of Captopril is not indicative of an allergic reaction, but rather a known adverse effect of ACE inhibitors. Therefore, this response is inappropriate for the situation described.
C. The client should contact their provider, who may switch them to a different medication:
A chronic dry cough is a common side effect of ACE inhibitors like Captopril, occurring in some individuals due to the accumulation of bradykinin. If the cough is bothersome, the best course of action is for the client to contact their healthcare provider. The provider may consider switching the patient to an angiotensin II receptor blocker (ARB), which does not typically cause this side effect. This is the most appropriate and safe action.
D. The client should stop taking the Lisinopril immediately:
Lisinopril is an ACE inhibitor, similar to Captopril, and shares the same potential side effects, including a chronic dry cough. However, the client should not stop taking their medication without consulting their healthcare provider. Discontinuing the medication abruptly can result in uncontrolled hypertension and other risks. The correct course of action is to contact the provider to discuss possible alternatives, not to stop the medication independently.
Correct Answer is A
Explanation
A) Wear a HEPA/N95 mask while providing care to the client:
Tuberculosis (TB) is a highly contagious airborne disease, and healthcare workers caring for patients with active TB must wear a HEPA/N95 mask to protect themselves from inhaling the bacteria. These specialized masks filter out airborne particles, including Mycobacterium tuberculosis, which can be spread through droplets when the patient coughs, sneezes, or talks. Wearing an N95 mask is an essential part of airborne precautions in the care of TB patients.
B) Instruct the nursing assistant to wear a surgical mask when entering the client's room:
A surgical mask does not offer adequate protection against airborne pathogens like the tuberculosis bacteria. While surgical masks can block large droplets, they do not filter out smaller, airborne particles, such as those from TB. N95/HEPA masks are necessary for anyone entering the room of a patient with active tuberculosis, including nursing assistants, to ensure they are protected from inhaling infectious particles.
C) Ensure the client is in a positive pressure room:
A positive pressure room is typically used for patients who are immunocompromised, such as those with neutropenia or undergoing organ transplants, to prevent infection from the environment. However, negative pressure rooms are required for patients with airborne diseases like tuberculosis. A negative pressure room ensures that air flows into the room but does not leave, containing any airborne pathogens and preventing their spread to other areas of the facility.
D) Have the client wear a HEPA/N95 mask when outside of their room:
If the client with active tuberculosis needs to leave their room for medical procedures or testing, they should wear a HEPA/N95 mask to prevent spreading the bacteria to others through airborne transmission. This helps limit exposure to other individuals, as TB can be transmitted by airborne particles.
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