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 ["C","E"]
Explanation
A. Applying a constricting bandage/gauze wrap is contraindicated. This could further compromise circulation and exacerbate ischemia.
B. Advising the client about an immediate amputation is inappropriate and outside the nurse's scope of practice. The focus should be on timely intervention and notifying the surgeon.
C. Preparing the client to go back to the operating room is appropriate because the symptoms indicate potential compartment syndrome or vascular compromise, which often requires surgical intervention to restore circulation.
D. Elevating the extremity and applying ice is contraindicated in this scenario. Elevation can further decrease blood flow to an already ischemic limb, and ice application can cause vasoconstriction, worsening the issue.
E. Notifying the surgeon is essential. The described symptoms are a surgical emergency requiring immediate evaluation and intervention to prevent permanent damage.
Correct Answer is C
Explanation
A. Increase the intake of cranberry juice is not recommended for clients with calcium oxalate kidney stones. While cranberry juice can help prevent urinary tract infections, it does not reduce the risk of kidney stones and may even contribute to stone formation in some cases due to its high oxalate content.
B. Increase sodium chloride intake is not advisable for clients with kidney stones. High sodium intake can increase calcium excretion in the urine, which may contribute to stone formation.
C. Drinking 1 L of fluid every day is not sufficient. For clients with a history of calcium oxalate kidney stones, it is generally recommended to drink at least 2-3 L of fluid per day to help dilute urine and prevent stone formation.
D. Increase intake of animal protein is not recommended for clients with calcium oxalate kidney stones. High animal protein intake can increase the excretion of calcium and uric acid in the urine, which can promote stone formation.
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.