A nurse is assessing a client who has diabetes mellitus and reports feeling dizzy and weak. Which of the following actions should the nurse take?
Check blood glucose level.
Give insulin injection.
Offer orange juice.
Apply cold compress.
The Correct Answer is A
Choice A reason: Checking blood glucose level is an appropriate action for the nurse to take because it can help determine if the client has hypoglycemia or hyperglycemia, which are both complications of diabetes mellitus that can cause dizziness and weakness. Blood glucose level should be checked using a glucometer and compared with the normal range of 70 to 130 mg/dL before meals and less than 180 mg/dL after meals.
Choice B reason: Giving insulin injection is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hypoglycemia, which is a condition in which blood glucose level drops below 70 mg/dL and can cause dizziness, weakness, confusion, sweating, and seizures. Insulin injection should be given according to the prescribed dose, type, and schedule.
Choice C reason: Offering orange juice is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hyperglycemia, which is a condition in which blood glucose level rises above 180 mg/dL and can cause dizziness, weakness, thirst, polyuria, and ketoacidosis. Orange juice should be offered only if the client has hypoglycemia and is conscious and able to swallow.
Choice D reason: Applying cold compress is not an appropriate action for the nurse to take because it does not address the underlying cause of dizziness and weakness in a client who has diabetes mellitus. Cold compress may worsen the symptoms by reducing blood flow and oxygen delivery to the brain. Cold compress should be applied only if the client has fever, inflammation, or pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Tapioca is a gluten-free food that can be recommended for a client who has celiac disease. Tapioca is a starch extracted from the cassava root, which is a tuber plant. Tapioca can be used to make puddings, breads, flours, and pearls.
Choice B reason: Barley is not a gluten-free food that can be recommended for a client who has celiac disease. Barley is a cereal grain that contains gluten, which is a protein that can trigger an immune response and damage the small intestine in people who have celiac disease. Barley should be avoided or replaced with gluten-free grains, such as rice, quinoa, or buckwheat.
Choice C reason: Cold cuts are not gluten-free foods that can be recommended for a client who has celiac disease. Cold cuts are sliced meats that are often processed and cured with additives, such as fillers, binders, and preservatives, that may contain gluten. Cold cuts should be avoided or checked for gluten-free labels before consuming.
Choice D reason: Flavored chips are not gluten-free foods that can be recommended for a client who has celiac disease. Flavored chips are snack foods that are often made from potatoes, corn, or rice, which are gluten-free ingredients, but they may also contain seasonings, spices, and sauces that may contain gluten. Flavored chips should be avoided or checked for gluten-free labels before consuming.
Correct Answer is A
Explanation
Choice A reason: Flushing the tubing with water every 4 hours can prevent the tubing from clogging by clearing any residual formula or medication from the lumen.
Choice B reason: Replacing the bag and tubing every 24 hours can prevent bacterial contamination, but it does not prevent the tubing from clogging.
Choice C reason: Administering the feeding by gravity drip can cause overfeeding, aspiration, or diarrhea, but it does not prevent the tubing from clogging.
Choice D reason: Heating the formula prior to infusion can cause bacterial growth, nutrient loss, or burns, but it does not prevent the tubing from clogging.
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