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 C
Explanation
Choice A reason: Eating more tuna is not an appropriate food choice for a client who has gout because it is high in purines, which are substances that break down into uric acid in the body. Uric acid can form crystals in the joints and cause inflammation and pain, which are symptoms of gout. Tuna should be limited or avoided by clients who have gout.
Choice B reason: Eating more red meat is not an appropriate food choice for a client who has gout because it is high in purines, which are substances that break down into uric acid in the body. Uric acid can form crystals in the joints and cause inflammation and pain, which are symptoms of gout. Red meat should be limited or avoided by clients who have gout.
Choice C reason: Eating blueberries every morning is an appropriate food choice for a client who has gout because they are low in purines and high in antioxidants, which are substances that protect the cells from damage caused by free radicals. Antioxidants can help reduce inflammation and pain, which are symptoms of gout. Blueberries also provide vitamin C, fiber, and water for the client.
Choice D reason: Eating bananas for a snack is not an appropriate food choice for a client who has gout because they are high in fructose, which is a type of sugar that can increase uric acid levels in the blood. Fructose can worsen gout attacks by triggering inflammation and pain in the joints. Bananas should be limited or avoided by clients who have gout.
Correct Answer is B
Explanation
Choice A reason: Telling the client to lie down after eating can increase the risk of aspiration pneumonia, as food or liquids can enter the lungs more easily when lying down.
Choice B reason: Instructing the client to tuck her chin when swallowing can help prevent aspiration pneumonia, as it closes off the airway and directs food or liquids into the esophagus.
Choice C reason: Placing the client in a Fowler's position to eat can help prevent aspiration pneumonia, as it elevates the head and chest and allows gravity to assist with swallowing.
Choice D reason: Encouraging the client to drink water before each meal can increase the risk of aspiration pneumonia, as it can thin out saliva and make it harder to control swallowing.
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