The patient's meal has been delivered, and the nurse checks the pre-meal blood sugar, which is 40 mg/dL. The patient is clammy, diaphoretic, and non-arousable.
What should the nurse do next?
Stay with the patient, call for help, and recheck the blood glucose results.
Follow the hypoglycemia protocol and administer medication to raise the blood glucose.
Closely monitor the patient and recheck the blood glucose level 15 minutes after administering glucose.
Notify the physician immediately without taking other actions.
The Correct Answer is B
Choice A rationale
Staying with the patient and rechecking blood glucose delays immediate corrective action required for severe hypoglycemia (40 mg/dL). While safety is important, prompt treatment with glucose is the priority to prevent further complications.
Choice B rationale
Following the hypoglycemia protocol ensures immediate glucose administration, either orally, intravenously, or intramuscularly, to stabilize the patient. This is critical as glucose levels below 40 mg/dL require urgent intervention to prevent neuronal damage or coma.
Choice C rationale
Monitoring and rechecking glucose after treating is essential but not sufficient as the first action. Hypoglycemia this severe needs immediate treatment before monitoring, ensuring prompt glucose replacement to prevent worsening symptoms.
Choice D rationale
Notifying the physician without treating the hypoglycemia risks unnecessary delays. Immediate action, such as administering glucose per protocol, is vital in this emergency scenario for patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Administering 1 mg of glucagon intramuscularly is unnecessary for a patient who is awake, alert, and able to swallow. Glucagon is reserved for patients who are unconscious and unable to swallow effectively to prevent choking.
Choice B rationale
Administering 25 g of dextrose IVP is unnecessary in this case because the patient is alert and able to swallow. Oral intake of carbohydrates is the preferred and safer intervention for mild hypoglycemia like 69 mg/dL.
Choice C rationale
Holding the insulin and encouraging the patient to eat provides glucose through dietary means, which is appropriate in a patient who is awake, alert, and hungry. A level of 69 mg/dL, though below normal, can be managed with oral glucose intake safely.
Choice D rationale
Calling the MD is not the immediate priority in managing mild hypoglycemia. Intervening directly to correct the glucose level with oral intake is more appropriate and effective in this situation.
Correct Answer is D
Explanation
Choice A rationale
Administering dextrose IVP is inappropriate for hyperglycemia. It elevates blood sugar further, risking complications like hyperosmolar hyperglycemic state. It is used to treat severe hypoglycemia instead.
Choice B rationale
Glucagon stimulates glycogen breakdown into glucose, increasing blood sugar. It is contraindicated in hyperglycemia, as it would aggravate elevated glucose levels. It is a treatment for severe hypoglycemia.
Choice C rationale
Holding insulin allows hyperglycemia to persist, increasing risks of complications like ketoacidosis. Insulin administration is essential to reduce the glucose level safely.
Choice D rationale
Rapid-acting insulin like Humalog reduces hyperglycemia efficiently, bringing preprandial blood glucose closer to the target range of 70-130 mg/dL. Administering 4 units is a reasonable corrective dose based on the blood glucose of 243 mg/dL.
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