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 ["A","D","E"]
Explanation
Choice A Reason: Cloudy urine is a finding that indicates a urinary tract infection, as it shows that there are bacteria, pus, or blood in the urine.
Choice B Reason: Muscle tetany is not a finding that indicates a urinary tract infection, but it may indicate other conditions such as hypocalcemia or alkalosis.
Choice C Reason: Presence of calculi is not a finding that indicates a urinary tract infection, but it may cause or complicate a urinary tract infection by obstructing the urine flow and creating a nidus for bacterial growth.
Choice D Reason: Urinary frequency is a finding that indicates a urinary tract infection, as it shows that there is irritation and inflammation of the bladder and urethra.
Choice E Reason: Dysuria is a finding that indicates a urinary tract infection, as it shows that there is pain or burning sensation during urination.
Correct Answer is D
Explanation
Choice A Reason: Hypertension is not a common finding in diabetes insipidus, but it may indicate increased intracranial pressure or other complications.
Choice B Reason: Fluid retention is not a common finding in diabetes insipidus, but it may indicate syndrome of inappropriate antidiuretic hormone secretion (SIADH) or heart failure.
Choice C Reason: Elevated blood glucose is not a common finding in diabetes insipidus, but it may indicate diabetes mellitus or hyperglycemia.
Choice D Reason: Increased urine output is a common finding in diabetes insipidus, as the lack of antidiuretic hormone (ADH) causes the kidneys to excrete large amounts of diluted urine.
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