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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.

Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.

Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.

Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.

A. Instruct the client to increase fluid intake. B. Notify the health care provider. C. Advise the client to take iron rich foods. D. Document the findings.

Correct Answer is B

Explanation

Choice A Reason: Instructing the client to increase fluid intake is not the most appropriate nursing action, as it does not address the cause or severity of the bleeding.

Choice B Reason: Notifying the health care provider is the most appropriate nursing action, as it indicates that the client may have a bleeding ulcer that requires immediate evaluation and treatment.

Choice C Reason: Advising the client to take iron rich foods is not the most appropriate nursing action, as it does not prevent or correct anemia or bleeding.

Choice D Reason: Documenting the findings is not the most appropriate nursing action, as it does not initiate any intervention or outcome.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

Correct Answer is D

Explanation

A client was admitted in the hospital with peptic ulcer disease tells the nurse about having black tarry stools. Which of the following is the most appropriate nursing action?

Correct Answer is B

Explanation

Which of the following clinical manifestations should a nurse expect from a client with hyperthyroidism? SELECT ALL THAT APPLY

A nurse is monitoring a client for findings related to diabetes insipidus following a craniotomy. Which of the following findings should indicate a manifestation of this condition to the nurse?

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following findings should the nurse expect?

The nurse is completing a health assessment of a client suspected of hyperthyroidism. Which of the following clinical manifestations should the nurse expect?

A nurse is collecting data from a client who has a urinary tract infection. Which of the following findings should the nurse expect? Select all that apply.

A nurse notes that a client's serum potassium level is 6 mEq/L. The nurse interprets this as an expected finding in the client with which health problem?

A nurse is assisting with data collection of a client with suspected cholecystitis. Which finding does the nurse expect to note if cholecystitis is present?