A nurse is caring for a client who has hypoglycemia.
The nurse should monitor the client for which of the following adverse effects of hypoglycemia?

Fever.

Shakiness.

Increased urination.

Thirst.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Fever. Fever is not an adverse effect of hypoglycemia. Fever is usually associated with an elevated body temperature, often due to infection or other inflammatory conditions, and is not directly related to low blood sugar levels.

Choice B rationale:

Shakiness. Shakiness is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body responds with symptoms like trembling or shakiness, which is caused by the release of stress hormones like epinephrine. These symptoms are the body's way of signaling the need for immediate glucose intake to raise blood sugar levels.

Choice C rationale:

Increased urination. Increased urination is not a typical symptom of hypoglycemia. In fact, frequent urination may be associated with hyperglycemia (high blood sugar levels) in conditions like diabetes mellitus.

Choice D rationale:

Thirst. Thirst is not a direct symptom of hypoglycemia. Thirst is more commonly associated with hyperglycemia, where high blood sugar levels lead to increased urine output, causing dehydration and subsequent thirst. In hypoglycemia, the focus is on correcting the low blood sugar levels rather than managing thirst.

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Correct Answer is B

Explanation

Choice A rationale:

Stimulate the infant to cry. Stimulating the infant to cry is an important step in newborn care, as crying helps to clear the respiratory passages and establish effective breathing. However, it should not be the first action taken, as there are more immediate priorities in newborn care.

Choice B rationale:

Clear the respiratory tract. Clearing the respiratory tract should be the first action taken when caring for a newborn following a vaginal delivery. The newborn may have mucus or amniotic fluid in the airway, which can obstruct breathing. Clearing the airway ensures that the infant can breathe effectively. This action takes precedence over other tasks.

Choice C rationale:

Dry the infant off and cover the head. Drying the infant off and covering the head is important for maintaining the infant's temperature and preventing heat loss. However, it is not the first priority when compared to clearing the respiratory tract. Establishing effective breathing is of utmost importance.

Choice D rationale:

Clamp the umbilical cord. Clamping the umbilical cord is typically done after the baby is breathing and stable. It is an important step in the immediate post-delivery care, but it should not be the first action taken. Clearing the respiratory tract and ensuring the infant can breathe take precedence.

A. Elevate the head of the client's bed for 1 hr after the feeding. B. Administer the feeding solution at a cold temperature. C. Rotate the jejunostomy tube once per day. D. Flush the tube with 90 mL of sterile water before and after the feeding.

Correct Answer is A

Explanation

Choice A rationale:

Elevating the head of the client's bed for 1 hour after the feeding is the correct choice because it helps reduce the risk of aspiration. Elevating the head of the bed at a 30-45 degree angle can promote the flow of enteral feeding solution into the jejunum, reducing the risk of reflux into the stomach and subsequent aspiration.

Choice B rationale:

Administering the feeding solution at a cold temperature is not recommended. Enteral feedings should be given at or near room temperature to prevent discomfort and cramping in the client.

Choice C rationale:

Rotating the jejunostomy tube once per day is not a standard practice. The tube should be secured in place to prevent dislodgement, but routine rotation is not necessary.

Choice D rationale:

Flushing the tube with 90 mL of sterile water before and after the feeding is not necessary for intermittent bolus enteral feedings. Flushing before and after continuous feedings may be required to maintain patency, but for intermittent bolus feedings, it is not a routine practice.

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A nurse is caring for a client who has hypoglycemia.The nurse should monitor the client for which of the following adverse effects of hypoglycemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a newborn following a vaginal delivery.Which of the following actions should the nurse perform first?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is caring for a client who has hypoglycemia.
The nurse should monitor the client for which of the following adverse effects of hypoglycemia?