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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Free Nursing Study Resources

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

Explanation

Choice A reason: Reviewing the last PTT results is important to ensure that the heparin therapy is within the therapeutic range and to assess for potential over-anticoagulation.

Choice B reason: Auscultating bowel sounds in all quadrants helps determine if there is any bowel obstruction or ileus, which can be associated with abdominal pain.

Choice C reason: Monitoring stools for the presence of blood is essential to identify gastrointestinal bleeding, which can present as tarry, black stools.

Choice D reason: Preparing to administer warfarin is not appropriate in the acute management of potential gastrointestinal bleeding and should be done based on the healthcare provider's instructions.

Choice E reason: Assessing the characteristics of pain is important to better understand the cause of abdominal pain and guide further management.

Correct Answer is ["1000"]

Explanation

Calculation Steps:

Step 1: Determine the total volume to be infused: 500 mL. Result = 500 mL.

Step 2: Convert time from minutes to hours: 30 minutes ÷ 60 minutes/hour = 0.5 hours. Result = 0.5 hours.

Step 3: Calculate the infusion rate: 500 mL ÷ 0.5 hours = 1000 mL/hour.

Result = 1000 mL/hour.

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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 client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

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

Explanation

The healthcare provider (HCP) prescribes 0.9% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

Correct Answer is ["1000"]

Explanation

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