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 B
Explanation
Choice A reason: Consuming ten percent of total calories from saturated fat is not a part of the DASH diet because it is too high for most adults. The DASH diet recommends consuming less than seven percent of total calories from saturated fat, which translates to about 16 g of saturated fat per day for an average adult who consumes 2,000 calories per day.
Choice B reason: Consuming foods that are high in calcium is a part of the DASH diet because it can help lower blood pressure by relaxing the blood vessels and reducing the force of contraction of the heart. The DASH diet recommends consuming 1,000 to 1,200 mg of calcium per day, which can be obtained from dairy products, leafy greens, beans, nuts, and fortified foods.
Choice C reason: Increasing intake of refined carbohydrates is not a part of the DASH diet because it can raise blood sugar and insulin levels, which can increase blood pressure and damage the blood vessels. The DASH diet recommends consuming 45 to 55 percent of total calories from carbohydrates, but mostly from whole grains, fruits, and vegetables, which are rich in fiber and antioxidants.
Choice D reason: Limiting sodium intake to 3,200 milligrams per day is not a part of the DASH diet because it is too high for most adults. The DASH diet recommends limiting sodium intake to 2,300 milligrams per day or less, which can help lower blood pressure by reducing fluid retention and vascular resistance.
Correct Answer is A
Explanation
Choice A reason: Alternating the first breast that is offered to the baby with each feeding can help ensure equal stimulation and drainage of both breasts, and prevent engorgement, mastitis, or milk supply problems.
Choice B reason: Storing breastmilk in the refrigerator up to 48 hours is not recommended, as it can reduce the quality and quantity of antibodies and nutrients in the milk. The optimal storage time for breastmilk in the refrigerator is up to 24 hours.
Choice C reason: Nursing the baby once every 4 hours is not sufficient, as it can lead to insufficient milk intake, dehydration, weight loss, or jaundice in the baby. The baby should be nursed on demand, or at least every 2 to 3 hours during the day and every 4 hours at night.
Choice D reason: Offering the baby water between feedings is not necessary, as it can interfere with breastfeeding and cause water intoxication or electrolyte imbalance in the baby. Breastmilk provides enough hydration and nutrition for the baby.
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