The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take?

Reference Ranges

Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Collect a blood sample for hemoglobin Alc.

Give the client a glass of orange juice.

Notify the healthcare provider.

Assess client for polyuria and polyphagia.

Answer and Explanation

The Correct Answer is B

In this situation, the client has a fingerstick glucose level of 35 mg/dL (1.94 mmol/L) and is alert but diaphoretic. The charge nurse should take the following action:

Give the client a glass of orange juice.

A glucose level of 35 mg/dL (1.94 mmol/L) is considered significantly low (hypoglycemia), and the client's symptoms of diaphoresis indicate that the low glucose level is likely causing the symptoms. Providing the client with a glass of orange juice or another source of fast-acting carbohydrate is appropriate to quickly raise the blood sugar level and alleviate the symptoms of hypoglycemia.

Collecting a blood sample for hemoglobin A1c (HbA1c) is not necessary in this acute situation. HbA1c reflects the average blood glucose level over the past 2-3 months and is used to assess long-term glycemic control in clients with diabetes. It does not provide immediate information or guide immediate interventions for acute hypoglycemia.

Notifying the healthcare provider is not the first action to take in this situation. The client's low glucose level can be promptly addressed by administering a source of fast-acting carbohydrate, such as orange juice. If the client's symptoms persist or worsen despite appropriate intervention, or if there are other concerning factors, then notifying the healthcare provider would be appropriate.

Assessing the client for polyuria (excessive urination) and polyphagia (excessive hunger) is important in the overall management of diabetes, but it is not the immediate action to take in this acute situation of hypoglycemia. The priority at this time is to address the low blood sugar level and relieve the client's symptoms.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Certain medications can contribute to constipation as a side effect. Reviewing the client's medication list will help identify any potential medications that may be causing or exacerbating constipation.

Understanding the client's current approach to managing constipation, such as dietary changes, laxative use, or other remedies, will provide insight into their self-care practices and effectiveness of current interventions.

Diet plays a crucial role in bowel regularity. Assessing the client's dietary habits, including fiber intake and hydration, can help identify potential factors contributing to constipation.

Physical activity and exercise promote bowel regularity by stimulating intestinal motility. Evaluating the client's level of physical activity and exercise routine can provide information on their overall mobility and potential impact on bowel function.

The next scheduled visit with the healthcare provider may be important for the overall management of the client's health but may not be directly related to formulating a plan of care specifically for constipation.

A. Wear protective goggles while performing the procedure. B. Apply a water soluble lubricant to the catheter. C. Instill 3 mL of normal saline before suctioning. D. Instruct the client to cough as the suction tip is removed.

Correct Answer is A

Explanation

Wearing protective goggles is important during suctioning to protect the nurse's eyes from potential splashes or aerosolized secretions. Suctioning can generate forceful coughing, gagging, or sneezing in the client, which may cause secretions or mucus to be expelled forcefully and potentially come into contact with the nurse's eyes. Wearing goggles helps prevent eye exposure and reduces the risk of infection transmission.

Applying a water-soluble lubricant to the catheter may be necessary to facilitate the insertion of the suction catheter into the tracheostomy tube, but it is not the most crucial action to include when performing suctioning.

Instilling normal saline before suctioning is not recommended as it can cause potential harm to the client's airway. Instilling saline can lead to bronchospasm, mucosal damage, and other complications. Suctioning should only be performed when necessary to remove secretions and maintain a patent airway.

Instructing the client to cough as the suction tip is removed is not necessary or recommended. Coughing during the suctioning process can be uncontrolled and may increase the risk of trauma to the airway. The nurse should instead provide supportive care and reassurance to the client throughout the procedure.

View Question and Answer

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

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take? Reference Ranges Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Correct Answer is A

Explanation

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress?

After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care?

The nurse is providing discharge teaching to a client who underwent a pneumonectomy. The client wants to resume social activities with family. How should the nurse respond?

A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?

The nurse is caring for a client newly diagnosed with emphysema. The nurse should prioritize which potential complication?

A client who has been taking allopurinol prophylactically comes into the clinic with reoccurring gout attack episodes in left ankle. The healthcare provider changes the prescription to febuxostat. Which instruction should the nurse include in the discharge teaching?

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take?

Reference Ranges

Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]