A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.

Check the client's current fingerstick blood glucose.

Obtain blood pressure and heart rate.

Administer a PRN dose of regular insulin.

Give the client 4 ounces (120 mL) of orange juice.

Provide the client with 1/2 cup (120 mL) diet carbonated soda.

Answer and Explanation

Correct Answer : A,D

Choice A reason: Checking the client's current fingerstick blood glucose is important to determine if the confusion and weakness are due to hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Choice B reason: Obtaining blood pressure and heart rate is useful for a general assessment but is secondary to assessing blood glucose levels in this scenario.

Choice C reason: Administering a PRN dose of regular insulin is not appropriate without first determining the client's blood glucose level. If the client is hypoglycemic, insulin could worsen the condition.

Choice D reason: Giving the client 4 ounces (120 mL) of orange juice is a quick way to raise blood sugar levels if the client is hypoglycemic.

Choice E reason: Providing diet carbonated soda is not effective for treating hypoglycemia because it does not contain sugar to raise blood glucose levels.

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Correct Answer is A

Explanation

Choice A reason: Reporting the client's jaw pain to the healthcare provider is essential because jaw pain can be a symptom of osteonecrosis of the jaw, a rare but serious side effect of bisphosphonate therapy.

Choice B reason: Advising the client to gargle with warm salt water may provide temporary relief, but it does not address the underlying issue of potential osteonecrosis.

Choice C reason: Determining how the client is administering the medication is important for proper use but does not address the immediate concern of jaw pain.

Choice D reason: Confirming that this is a common symptom of osteoporosis is incorrect. Jaw pain is not a common symptom of osteoporosis and requires further evaluation.

A. Observe neck for jugular vein distention. B. Monitor oxygen saturation via continuous pulse oximetry. C. Notify healthcare provider to prepare for pericardiocentesis. D. Assess for paradoxical blood pressure.

Correct Answer is C

Explanation

Choice A reason: Observing for jugular vein distention is important but not the immediate intervention.

Choice B reason: Monitoring oxygen saturation is necessary but secondary to preparing for pericardiocentesis.

Choice C reason: Pericardiocentesis is the definitive treatment for cardiac tamponade, and notifying the healthcare provider to prepare for this procedure is the most important intervention.

Choice D reason: Assessing for paradoxical blood pressure helps confirm cardiac tamponade but does not address the immediate need for treatment.

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A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is A

Explanation

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

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