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.
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Related Questions
Correct Answer is B
Explanation
A. Administration of IV antibiotics is not appropriate for this client, as there is no indication of an infection. The client's symptoms are consistent with fluid overload due to heart failure, not an infectious process.
B. Administration of IV diuretics is the priority intervention. The client is exhibiting signs of fluid overload, including jugular venous distention, crackles, and a bounding pulse. IV diuretics, such as furosemide, help reduce fluid volume, alleviate pulmonary congestion, and improve breathing.
C. Isotonic intravenous fluids would exacerbate the fluid overload and worsen the client's symptoms. This intervention is contraindicated in this scenario.
D. Laying the client supine with legs elevated is inappropriate for a client with heart failure and fluid overload, as it can increase venous return to the heart and worsen pulmonary congestion. Instead, the client should be positioned upright to improve breathing.
Correct Answer is A
Explanation
A. A potassium level of 3.3 mEq/L indicates hypokalemia, which can lead to cardiac dysrhythmias due to the role of potassium in maintaining normal cardiac conduction and muscle contraction. Monitoring the client’s heart rhythm is crucial.
B. Neurogenic shock is not a complication of hypokalemia. It is typically caused by spinal cord injury or central nervous system damage, not electrolyte imbalances.
C. Hypoglycemia is not directly associated with hypokalemia or furosemide use. Furosemide primarily affects fluid and electrolyte balance, not glucose regulation.
D. While severe hypokalemia can cause neuromuscular issues, seizures are more commonly associated with conditions like hyponatremia or hypocalcemia, not hypokalemia.
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