A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?

Bradycardia

Flushed skin

Decreased appetite

Tremors

Answer and Explanation

The Correct Answer is D

A. Bradycardia:
Low blood sugar levels can lead to bradycardia, a slower than normal heart rate.

B. Flushed skin:
Typically, low blood sugar levels might cause pallor or cool, clammy skin, rather than flushing.x

C. Decreased appetite:
Low blood sugar might result in increased hunger or a feeling of needing to eat rather than decreased appetite.

D. Tremors:
Hypoglycemia often presents with symptoms like tremors or shakiness due to the body's response to low blood sugar.

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Correct Answer is C

Explanation

A. Height of the IV pole:
Explanation: The height of the IV pole is important for controlling the rate of the TPN infusion. Adjusting the height can regulate the flow rate.

B. IV insertion site:
Explanation: Monitoring the IV insertion site is crucial to assess for signs of infection, inflammation, or infiltration, which can compromise the effectiveness of TPN.

C. Manifestations of hypoglycemia:
Explanation: TPN often contains glucose, and monitoring for signs of hypoglycemia is important, as abrupt cessation of TPN can lead to low blood glucose levels.

D. The client's oral intake:
Explanation: Since the client is receiving TPN, their oral intake is not the primary source of nutrition. TPN provides essential nutrients intravenously.

A. Metoprolol 50 mg. PO daily. B. Maintain accurate intake and output records. C. Furosemide Lasix 40 mg push. D. Encourage fluid intake, more than 2000 mL/day.

Correct Answer is C

Explanation

A. Metoprolol 50 mg PO daily:
This is a beta-blocker that helps lower blood pressure and heart rate. While it may be part of managing heart failure, it is not the immediate priority in a client presenting with signs of fluid overload and congestion.

B. Maintain accurate intake and output records:
Monitoring intake and output is important in managing fluid balance.
However, in this situation, the priority is to address the existing fluid overload promptly.

C. Furosemide (Lasix) 40 mg push:
Furosemide is a loop diuretic that promotes the excretion of excess fluid. Administering it "push" implies a more rapid onset of action, making it suitable for addressing acute fluid overload.

D. Encourage fluid intake, more than 2000 mL/day:
In the context of fluid overload, encouraging additional fluid intake is contraindicated. The focus should be on removing excess fluid with diuretic therapy rather than promoting more intake.

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A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?

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