A client reports confusion and blurred vision after receiving a dose of glipizide. Which action should the nurse implement?

Perform a neurological exam.

Obtain a fingerstick blood glucose.

Administer glucagon intramuscularly.

Measure the client's vital signs.

Answer and Explanation

The Correct Answer is B

Choice A reason: Performing a neurological exam is not the priority action in this situation. Confusion and blurred vision are signs of hypoglycemia, which is a low blood sugar level. Glipizide is a medication that lowers blood sugar by stimulating the pancreas to produce more insulin. The nurse should first confirm the blood sugar level before performing any other assessments or interventions.

Choice B reason: Obtaining a fingerstick blood glucose is the best action in this situation. This is a quick and easy way to measure the blood sugar level and determine if the client is experiencing hypoglycemia. The nurse should use a glucometer and a lancet to prick the client's finger and obtain a drop of blood. The nurse should compare the result with the normal range and follow the hypoglycemia protocol.

Choice C reason: Administering glucagon intramuscularly is not the first action in this situation. Glucagon is a hormone that raises blood sugar by stimulating the breakdown of glycogen in the liver. It is used as an emergency treatment for severe hypoglycemia, when the client is unconscious or unable to swallow. The nurse should only administer glucagon after confirming the blood sugar level and trying oral glucose first.

Choice D reason: Measuring the client's vital signs is not the priority action in this situation. Vital signs include blood pressure, pulse, respiration, and temperature. They can provide information about the client's overall health and stability, but they are not specific to hypoglycemia. The nurse should focus on the blood sugar level, which is the most relevant indicator of hypoglycemia.

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Correct Answer is C

Explanation

Choice A reason: Diarrhea is not a contraindication for phenylephrine, which is a decongestant that reduces swelling and mucus in the nasal passages. However, the nurse should monitor the client's fluid and electrolyte balance and provide adequate hydration.

Choice B reason: Bronchitis is not a contraindication for phenylephrine, which may help relieve some of the symptoms of bronchitis, such as nasal congestion and cough. However, the nurse should also encourage the client to use other measures, such as steam inhalation, expectorants, and rest.

Choice C reason: Hypertension is a contraindication for phenylephrine, which can increase blood pressure and heart rate by constricting blood vessels. The nurse should report this condition to the healthcare provider and withhold the medication until further orders.

Choice D reason: Edema is not a contraindication for phenylephrine, which does not affect fluid retention or distribution. However, the nurse should assess the cause of edema and monitor the client's weight and urine output.

A. When using the discus, have the client breathe out rapidly into the mouthpiece. B. Offer the discus to the client for use during an acute asthma attack. C. Clients using the discus may experience decreased blood pressure. D. Explain that the client should not use the discus more than twice daily.

Correct Answer is D

Explanation

Choice A reason: This is not a correct instruction for the nurse to provide to the client's caregivers. When using the discus, the client should breathe out slowly and gently away from the mouthpiece, not into it. Breathing out rapidly into the mouthpiece can cause the powder to disperse and reduce the amount of medication delivered to the lungs. The client should also rinse the mouthpiece with water after each use and dry it thoroughly.

Choice B reason: This is not a correct instruction for the nurse to provide to the client's caregivers. The discus is not intended for use during an acute asthma attack, as it does not provide immediate relief of bronchospasm. The discus is a combination of fluticasone, a corticosteroid that reduces inflammation, and salmeterol, a long-acting beta-agonist that relaxes the airway muscles. The discus is a maintenance therapy that should be used regularly to prevent asthma symptoms and exacerbations. The client should also have a rescue inhaler, such as albuterol, for quick relief of asthma attacks.

Choice C reason: This is not a correct instruction for the nurse to provide to the client's caregivers. Clients using the discus may experience increased blood pressure, not decreased, as a possible side effect of salmeterol. Salmeterol can stimulate the beta receptors in the heart and blood vessels, causing tachycardia, palpitations, and hypertension. The nurse should monitor the client's blood pressure and heart rate regularly and report any abnormal findings to the healthcare provider.

Choice D reason: This is the correct instruction for the nurse to provide to the client's caregivers. The discus should not be used more than twice daily, as it can increase the risk of adverse effects and reduce the effectiveness of the medication. The discus should be used once in the morning and once in the evening, about 12 hours apart, to provide optimal control of asthma symptoms. The nurse should teach the client and the caregivers how to use the discus correctly and safely, and to follow the prescribed dosage and schedule.

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A client reports confusion and blurred vision after receiving a dose of glipizide. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with nasal congestion receives a prescription for phenylephrine 10 mg by mouth every 4 hours. Which client condition should the nurse report to the healthcare provider before administering the medication?

Correct Answer is C

Explanation

To control asthma, a client in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system, which provides an inhaled powdered form of these combined medications. Which instruction should the nurse provide to this client's caregivers?

Correct Answer is D

Explanation

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