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 B
Explanation
A. Graham crackers: Hard, crunchy foods can trigger pain by irritating the trigeminal nerve, making them unsuitable for clients with trigeminal neuralgia. Soft, easy-to-swallow foods are preferred.
B. Vanilla pudding: Soft, smooth-textured foods are recommended to minimize irritation of the trigeminal nerve. Vanilla pudding requires minimal chewing, reducing the risk of triggering pain.
C. Ice cream: Extremely cold foods can act as a trigeminal nerve irritant and may provoke pain episodes. Lukewarm or room-temperature foods are preferable.
D. Vegetable soup: Although liquid-based, vegetable soup often contains solid pieces that require chewing, which can increase the risk of triggering pain. Blended or pureed soups are a better option.
Correct Answer is B
Explanation
A. Closing the inline clamp is necessary when the catheter is not in use to prevent air embolism, but it is not a required step before administering medication. The nurse should focus on flushing and checking for patency before medication administration.
B. Flushing the catheter with 10 mL of 0.9% sodium chloride before and after medication administration helps maintain patency, prevents occlusion, and ensures the catheter is functioning properly. This step is essential to avoid complications such as clot formation.
C. Applying a local anesthetic is not needed for routine medication administration through a nontunneled percutaneous central catheter. Anesthetic use is typically reserved for procedures like catheter insertion or painful dressing changes.
D. Donning sterile gloves is not required for medication administration through a central line. Clean gloves are sufficient, while sterile technique is reserved for dressing changes and catheter insertions.
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