A client on glipizide, a sulfonylurea, reports to the nurse feeling anxious, sweaty & has a headache. The nurse's initial action is to:
take vital signs.
administer 1 mg glucagon subcutaneously.
obtain a blood glucose reading.
notify the physician.
The Correct Answer is C
A. While taking vital signs can provide useful information about the client's overall condition, it does not address the immediate concern of potential hypoglycemia. The priority is to assess blood glucose levels directly.
B. Glucagon can be administered in cases of severe hypoglycemia where the patient is unable to ingest glucose orally. However, before administering glucagon, the nurse should first check the blood glucose level to confirm hypoglycemia.
C. Checking the blood glucose level will provide immediate information about whether the client is experiencing hypoglycemia. If the blood glucose is low, appropriate treatment (such as administering glucose or a fast-acting carbohydrate) can be initiated. If it’s within normal limits, other causes for the symptoms can be explored.
D. While it may be necessary to notify the physician depending on the outcome of the blood glucose reading or if the client’s condition worsens, it is not the first action. Immediate assessment of the blood glucose level is essential to determine the correct course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Teaching the client about maintaining a healthy weight is crucial, as weight management is a key factor in preventing the progression from prediabetes to type 2 diabetes. Losing even a small percentage of body weight can significantly improve insulin sensitivity and reduce the risk of developing diabetes.
B. At a fasting plasma glucose level of 120 mg/dL, the client is not at the stage where insulin therapy is indicated. Insulin is typically reserved for those with diabetes who require it for glycemic control. The focus should be on lifestyle changes rather than pharmacological treatment at this time.
C. Similar to insulin, oral hypoglycemic agents are generally not prescribed for clients with prediabetes. The goal is to manage blood glucose levels through lifestyle changes, and medication is typically introduced only if the client progresses to diabetes.
D. While self-monitoring of blood glucose is important for individuals with diabetes, it may not be necessary for someone with a fasting plasma glucose level of 120 mg/dL unless specifically indicated by a healthcare provider. Education could include how to monitor if they develop diabetes in the future, but the immediate focus should be on prevention strategies.
Correct Answer is B
Explanation
A. While exercise is an important aspect of diabetes management, particularly for blood glucose control and overall health, it is not the immediate priority for a newly diagnosed client. Understanding how to manage blood glucose levels is more critical initially.
B. For a client who is newly diagnosed with insulin-dependent diabetes, learning how to administer insulin is essential. This includes understanding how to prepare, inject, and store insulin, as well as recognizing the signs of hypoglycemia and hyperglycemia. Proper insulin administration is crucial for managing blood glucose levels and preventing complications.
C. Understanding dietary management is important in diabetes care, as it plays a significant role in blood sugar control. However, without knowing how to administer insulin, a client may struggle to manage their blood glucose levels effectively, making insulin administration a higher priority initially.
D. While monitoring urine for ketones is important, particularly in cases of potential diabetic ketoacidosis (DKA), this is not the first priority for a newly diagnosed client. The focus should be on fundamental skills and knowledge for managing diabetes, such as insulin administration.
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