The nurse is caring for a female client with type 2 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:
15 to 20 g of a fast-acting carbohydrate such as orange juice.
I.V. bolus of dextrose 50%.
I.M. or subcutaneous glucagon.
10 U of fast-acting insulin
The Correct Answer is C
A. 15 to 20 g of a fast-acting carbohydrate such as orange juice:
This is a standard and initial treatment for hypoglycemia. Fast-acting carbohydrates, like orange juice or glucose tablets, can quickly raise blood sugar levels. However, in the scenario described, the client is still conscious, and glucagon may be a more appropriate choice.
B. I.V. bolus of dextrose 50%:
Intravenous (IV) dextrose is a more aggressive intervention and is typically reserved for severe cases of hypoglycemia or for unconscious patients. It is not the first-line treatment for conscious patients.
C. I.M. or subcutaneous glucagon:
Glucagon is a hormone that raises blood sugar levels by promoting the conversion of stored glycogen in the liver to glucose. It is administered either intramuscularly (I.M.) or subcutaneously. In a conscious patient with hypoglycemia who cannot take oral carbohydrates, glucagon can be an effective and rapid way to raise blood sugar levels.
D. 10 U of fast-acting insulin:
Administering more insulin in a situation of hypoglycemia would worsen the condition. The goal in hypoglycemia is to raise blood sugar, and giving more insulin would have the opposite effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 30 minute onset; 2-hour duration: This does not accurately represent the onset and peak action time of Insulin Lispro.
B. 15 minute onset; 30-60 minutes peak: This is correct. Insulin Lispro has a rapid onset (starts working within 15 minutes) and a peak action time of 30-60 minutes after administration.
C. 2-hour onset; 12-hour duration: This is not accurate for rapid-acting insulin. Rapid-acting insulin has a much quicker onset and shorter duration compared to this option.
D. 15 minute onset; no peak (continuous): While the onset time is correct, stating "no peak" is not entirely accurate. Rapid-acting insulin does have a peak, but it's relatively short, occurring within the first hour after administration.
Correct Answer is A
Explanation
A. Respiratory acidosis:
This occurs when there is inadequate removal of carbon dioxide (CO2) by the respiratory system. In the case of the patient post-op from knee surgery receiving Morphine, the opioid can cause respiratory depression, leading to the retention of CO2 and the development of respiratory acidosis. Signs include a decreased respiratory rate and drowsiness.
B. Hypokalemia:
This is a condition characterized by low levels of potassium in the blood. While opioids can cause constipation, they are not directly associated with hypokalemia.
C. Metabolic acidosis:
This occurs when there is an increase in acid production or a loss of bicarbonate, leading to an imbalance in the body's acid-base status. The symptoms of metabolic acidosis are not typically associated with opioid use.
D. Respiratory alkalosis:
This occurs when there is excessive elimination of CO2, leading to decreased carbon dioxide levels in the blood. Opioids, especially in higher doses, are more likely to cause respiratory depression and acidosis rather than alkalosis. The patient's low respiratory rate and drowsiness are indicative of respiratory acidosis rather than alkalosis.
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