A nurse is caring for a client who has diabetes mellitus and cool, clammy skin. The client begins having a seizure. Which of the following treatments should the nurse administer?
Glucagon 1 mg IM
Continuous IV infusion of regular insulin
10 g of oral glucose gel
1 L bolus of 0.45% sodium chloride over 1 hr
The Correct Answer is A
A. Glucagon 1 mg IM: Glucagon is used to treat severe hypoglycemia when the client is unconscious, having seizures, or unable to take oral glucose. It stimulates glycogen breakdown in the liver, raising blood glucose levels. IM administration is appropriate for rapid effect in an emergency.
B. Continuous IV infusion of regular insulin: Insulin lowers blood glucose levels, which would worsen hypoglycemia. Administering insulin in this situation is inappropriate and could exacerbate the client’s condition.
C. 10 g of oral glucose gel: Oral glucose is suitable for mild to moderate hypoglycemia in a conscious client. However, since the client is experiencing a seizure, they are unable to swallow safely, making this option unsafe.
D. 1 L bolus of 0.45% sodium chloride over 1 hr: Hypoglycemia is not primarily treated with IV fluids unless the client is severely dehydrated. The priority in this case is to correct the low blood glucose level rather than administering hypotonic fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Begin a weight-bearing exercise program: Activities like walking, dancing, and resistance training help maintain bone density by stimulating osteoblast activity. Regular weight-bearing exercise strengthens bones and reduces the risk of fractures.
B. Avoid practicing yoga: Yoga can actually be beneficial for individuals with osteoporosis by improving balance, flexibility, and posture. However, certain high-impact or extreme bending poses should be avoided.
C. Continue jogging 1 to 2 miles per day: High-impact activities such as jogging can increase the risk of fractures in individuals with osteoporosis. Lower-impact exercises like walking or strength training are safer alternatives.
D. Walk at least 60 min every day: While walking is a good low-impact exercise, excessive walking without resistance or strength training may not provide sufficient bone-strengthening benefits. A structured weight-bearing exercise program is more effective.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The first action the nurse should take is assess for dizziness when standing followed by increase dietary iron intake.
Rationale:
Assess for dizziness when standing: The client’s orthostatic hypotension (BP drops from 132/60 to 102/50 mmHg upon standing) and tachycardia (HR 108/min) suggest possible symptomatic anemia. Evaluating for dizziness ensures client safety and helps determine the severity of anemia-related hypoxia.
Increase dietary iron intake: The client has iron deficiency anemia (low hemoglobin, hematocrit, RBC count, and ferritin). Since they follow a vegan diet, increasing plant-based iron sources (e.g., leafy greens, legumes, fortified cereals) and vitamin C intake can improve iron absorption.
Incorrect:
Administer IV fluids: While anemia can cause orthostatic hypotension, fluid resuscitation is not the first-line intervention unless dehydration is present.
Check for signs of bleeding: The client reports no pain or discomfort, and there is no evidence of active bleeding. Anemia is more likely due to chronic dietary deficiency rather than acute blood loss.
Administer vitamin B12 supplements: The client’s vitamin B12 level is slightly low but not critically deficient. The primary issue is iron deficiency, not pernicious anemia.
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