The nurse is caring for a client with a blood glucose reading of 620 mg/dL. The nurse would expect all of the following interventions except which?
Antihypertensive medication
Fluid replacement
Potassium laboratory monitoring
Insulin IV infusion
The Correct Answer is A
A. Antihypertensive medication is not a priority intervention for a client with a blood glucose level of 620 mg/dL, which indicates hyperglycemia, likely due to diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). The focus should be on correcting the hyperglycemia and preventing complications like dehydration or electrolyte imbalances.
B. Fluid replacement is essential to treat dehydration caused by hyperglycemia, as high blood glucose levels cause osmotic diuresis.
C. Potassium laboratory monitoring is crucial because insulin treatment can shift potassium into cells, potentially causing hypokalemia, so monitoring is necessary during treatment.
D. Insulin IV infusion is necessary to lower the blood glucose level in clients with severe hyperglycemia, such as in DKA or HHS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. 50% Dextrose in Water (D50W) IV push is the most appropriate intervention for a client with a blood glucose level of 30 mg/dL, indicating severe hypoglycemia. The rapid administration of D50W will quickly raise the blood glucose level and help restore consciousness.
B. Insulin Regular IV push would lower the blood glucose level, which is not appropriate in this situation where the client is hypoglycemic.
C. 0.9% sodium chloride infusion is a general fluid replacement solution, but it will not address the client's low blood glucose level.
D. 5% Dextrose continuous IV infusion is typically used for maintenance, but it would not act as quickly as D50W to correct severe hypoglycemia in an unconscious patient.
Correct Answer is C
Explanation
A. This statement is incorrect. Lispro is a rapid-acting insulin, and its duration of action is much shorter than 24 hours. It is typically effective for about 3-5 hours.
B. Administering Lispro 60 minutes before meals would be too early, as it peaks in about 1-2 hours after injection and works best when given closer to meal times.
C. Lispro should be administered 15-30 minutes before meals to match the onset of action, which begins within 15 minutes of injection. This timing allows the insulin to be active when blood glucose rises after eating.
D. Lispro does not require administration 2-6 hours before meals, as this would not align with its rapid onset of action.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.