A client is brought to the emergency room unconscious, with a pulse, and with a blood glucose of 40. The client is wearing a Medic-Alert bracelet indicating that he has Type 1 diabetes mellitus.
What order should the nurse anticipate?
Give glucagon.
Give orange juice.
Perform CPR.
Give insulin.
The Correct Answer is A
Choice A rationale:
Glucagon directly addresses the underlying issue of severe hypoglycemia: In a patient with Type 1 diabetes mellitus, a blood glucose level of 40 mg/dL signifies a critical condition known as severe hypoglycemia. This condition occurs when blood sugar levels drop dangerously low, depriving the brain and other vital organs of glucose, their primary source of energy. Glucagon, a hormone that acts opposite to insulin, is the most effective and rapid treatment for severe hypoglycemia. It works by stimulating the liver to release stored glucose into the bloodstream, quickly raising blood sugar levels and restoring normal brain function.
Rationale for other choices:
Choice B: Give orange juice: While orange juice contains carbohydrates that can raise blood sugar, it is not ideal for treating severe hypoglycemia due to its slower absorption rate compared to glucagon. In an unconscious patient, there's also a risk of aspiration if given orally.
Choice C: Perform CPR: CPR is not indicated in this scenario as the patient has a pulse. CPR is a lifesaving technique that is only used when a person's heart has stopped beating.
Choice D: Give insulin: Insulin, which lowers blood glucose, would be contraindicated in this situation as the patient is already experiencing severe hypoglycemia. Administering insulin would further decrease blood sugar levels, worsening the patient's condition.
Key points to remember:
Severe hypoglycemia is a medical emergency that requires prompt treatment with glucagon.
Glucagon is the only medication that can effectively and quickly raise blood glucose levels in severe hypoglycemia. It's crucial to administer glucagon as soon as possible to prevent irreversible brain damage or even death.
Healthcare professionals should be proficient in recognizing the signs and symptoms of severe hypoglycemia and administering glucagon appropriately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
NPH insulin is an intermediate-acting insulin that typically peaks 6-12 hours after administration.
Given that the insulin was administered at 1700 (5:00 PM), the peak action would be expected to occur between 2100 (9:00 PM) and 0500 (5:00 AM).
This time frame aligns with the known pharmacokinetics of NPH insulin.
It's crucial for nurses to be aware of the peak action times of different insulin types to effectively manage blood glucose levels and adjust insulin doses accordingly.
Choice B rationale:
Incorrect. NPH insulin does have a peak action, as explained above.
It's important to understand that even intermediate-acting insulins have a period of peak activity when they exert their strongest glucose-lowering effect.
Choice C rationale:
Incorrect. This time frame is too early to represent the peak action of NPH insulin. The peak action typically occurs later, between 6-12 hours after administration.
Choice D rationale:
Incorrect. This time point is too specific to accurately represent the peak action of NPH insulin.
The peak action can vary within the 6-12 hour window, depending on individual factors and injection site.
Correct Answer is A
Explanation
Choice A rationale:
Hypoglycemia is the most frequent side effect of insulin administration. It occurs when blood glucose levels drop too low, typically below 70 mg/dL.
Insulin is a hormone that plays a key role in regulating blood glucose levels. It works by promoting the uptake of glucose from the bloodstream into cells, where it can be used for energy.
When too much insulin is administered, or when blood glucose levels are already low, it can lead to hypoglycemia. Symptoms of hypoglycemia can vary, but they often include:
Shakiness Sweating Anxiety Hunger Palpitations Confusion Dizziness Blurred vision Seizures
Loss of consciousness
If hypoglycemia is not treated promptly, it can lead to serious complications, such as coma or death.
Therefore, it is important to be aware of the signs and symptoms of hypoglycemia and to take steps to prevent it. This may involve monitoring blood glucose levels regularly, adjusting insulin doses as needed, and carrying a source of fast-acting glucose, such as glucose tablets or juice, to treat hypoglycemia if it occurs.
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