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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Telling the client to expect a decrease in urine output is not an appropriate intervention for a client who has urolithiasis, as it may indicate dehydration, obstruction, or infection.
Choice B Reason: Encouraging the client to drink 3 L of fluids per day is an appropriate intervention for a client who has urolithiasis, as it helps to flush out stones, prevent new stone formation, and reduce urinary concentration.
Choice C Reason: Providing the client with a high protein diet is not an appropriate intervention for a client who has urolithiasis, as it may increase uric acid and calcium excretion and promote stone formation.
Choice D Reason: Maintaining the client on bed rest is not an appropriate intervention for a client who has urolithiasis, as it may decrease renal perfusion and increase urinary stasis.
Correct Answer is A
Explanation
Choice A Reason: Determining the client's calcium level is the appropriate action for the nurse to take, as it may indicate hypocalcemia, which is a possible complication of thyroidectomy due to accidental removal or damage of the parathyroid glands. Hypocalcemia can cause muscle spasms, tingling, numbness, or tetany.
Choice B Reason: Monitoring the client's peripheral pulses is not the appropriate action for the nurse to take, as it does not address the cause of muscle spasms or provide any relief.
Choice C Reason: Administering IV normal saline solution is not the appropriate action for the nurse to take, as it does not correct hypocalcemia or prevent further complications.
Choice D Reason: Giving the client an oral potassium supplement is not the appropriate action for the nurse to take, as it may worsen hypocalcemia or cause hyperkalemia, which can affect cardiac function and muscle contraction.
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