A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed and the pulse and respiratory rate are increased from the client's baseline. The nurse would first take which action?

Assist the RN to prepare an intravenous (IV) insulin infusion.

Give the client 4 oz of orange juice.

Check the client's capillary blood glucose.

Assist the RN to administer 50% dextrose.

Answer and Explanation

The Correct Answer is C

Choice A Reason: Assisting the RN to prepare an IV insulin infusion is not the first action that the nurse should take, as it may not be appropriate for the client's condition without knowing the blood glucose level.

Choice B Reason: Giving the client 4 oz of orange juice is not the first action that the nurse should take, as it may worsen the client's condition if the blood glucose level is high.

Choice C Reason: Checking the client's capillary blood glucose is the first action that the nurse should take, as it helps to determine if the client has hyperglycemia or hypoglycemia and guides the appropriate intervention.

Choice D Reason: Assisting the RN to administer 50% dextrose is not the first action that the nurse should take, as it may be harmful for the client if the blood glucose level is high.

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Correct Answer is C

Explanation

Choice A Reason: Cushing's is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excess cortisol and aldosterone production.

Choice B Reason: Diabetes insipidus is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive water loss and dilution of blood.

Choice C Reason: Addison's is an expected health problem in a client with high potassium level, as it causes high potassium level due to insufficient cortisol and aldosterone production.

Choice D Reason: Diarrhea is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive fluid and electrolyte loss.

A. Sharing personal hygiene items like razors B. Unprotected sexual activity C. Eating uncooked foods D. Getting a tattoo

Correct Answer is C

Explanation

Choice A Reason: Sharing personal hygiene items like razors is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, which are blood-borne infections.

Choice B Reason: Unprotected sexual activity is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, or other sexually transmitted infections.

Choice C Reason: Eating uncooked foods is a common way of spreading hepatitis A, as the virus can contaminate food or water that has been exposed to fecal matter from an infected person.

Choice D Reason: Getting a tattoo is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, or other blood-borne infections, if the equipment is not properly sterilized.

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A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed and the pulse and respiratory rate are increased from the client's baseline. The nurse would first take which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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