The nurse is caring for a patient with type 2 diabetes who reports diaphoresis and palpitations. A blood glucose check reveals a level of 55 mg/dL. What is the nurse's immediate intervention?

Recheck blood glucose immediately.

Provide 15 grams of fast-acting carbohydrates.

Administer 1 mg of glucagon intramuscularly.

Prepare an insulin subcutaneous injection.

Answer and Explanation

The Correct Answer is B

Choice A reason: Rechecking blood glucose immediately is not the appropriate immediate intervention when a patient shows signs of hypoglycaemia with a blood glucose level of 55 mg/dL. Immediate treatment is needed to raise the blood glucose level to prevent further complications.

Choice B reason: Providing 15 grams of fast-acting carbohydrates is the immediate intervention for a patient with hypoglycaemia. Fast-acting carbohydrates such as glucose tablets, juice, or regular soda can quickly raise blood glucose levels. This intervention addresses the immediate need to correct hypoglycaemia symptoms such as diaphoresis and palpitations.

Choice C reason: Administering 1 mg of glucagon intramuscularly is typically reserved for severe hypoglycaemia when the patient is unconscious or unable to ingest carbohydrates. In this scenario, the patient is conscious and able to consume fast-acting carbohydrates.

Choice D reason: Preparing an insulin subcutaneous injection is not appropriate for treating hypoglycaemia. Insulin lowers blood glucose levels and would worsen the patient's hypoglycaemic state.

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Correct Answer is C

Explanation

Choice A reason: Potassium supplements can actually be important for patients on diuretic therapy, especially if they are taking loop diuretics like furosemide, which can cause potassium loss. However, it is important to monitor potassium levels and follow the physician's guidance on supplement use.

Choice B reason: Instructing the patient to take diuretics at bedtime is not recommended. Diuretics should be taken in the morning to avoid frequent urination during the night, which can disrupt sleep.

Choice C reason: Notifying the physician if weight increases by three pounds in one week is a key instruction for patients with heart failure. Rapid weight gain can indicate fluid retention and worsening heart failure, requiring prompt medical evaluation and adjustment of treatment.

Choice D reason: Administering diuretics in the morning and notifying the physician of decreased urine output is important, but the focus on notifying the physician about significant weight gain provides a more specific and actionable guideline for managing heart failure.

A. Increase the rate of the transfusion to complete it as quickly as possible. B. Stop the transfusion immediately and document the amount infused. C. Continue the transfusion and monitor vital signs every 15 minutes. D. Continue the transfusion at the current rate until it is completed.

Correct Answer is B

Explanation

Choice A reason: Increasing the rate of the transfusion to complete it as quickly as possible is not safe. Blood transfusions should be completed within four hours to prevent complications such as bacterial contamination and hemolysis.

Choice B reason: Stopping the transfusion immediately and documenting the amount infused is the appropriate intervention. Blood products that have been transfusing for more than four hours must be stopped to ensure patient safety and prevent adverse reactions. Documentation ensures that the healthcare team is aware of the situation and can take appropriate follow-up actions.

Choice C reason: Continuing the transfusion and monitoring vital signs every 15 minutes is not appropriate after the four-hour window has passed. The risk of complications increases with prolonged transfusion times.

Choice D reason: Continuing the transfusion at the current rate until it is completed is not safe. The transfusion must be stopped after four hours to prevent potential complications.

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The nurse is caring for a patient with type 2 diabetes who reports diaphoresis and palpitations. A blood glucose check reveals a level of 55 mg/dL. What is the nurse's immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing students are preparing a care plan for a patient with heart failure. The patient will be prescribed diuretic therapy after discharge. What evidence-based instructions will the nurse include in this plan?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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