A nurse is verifying a record of informed consent for a client who is scheduled for surgery. Which of the following actions should the nurse take?

The correct answer is choice C. A client who was just given a glass of orange juice for a low blood glucose level.

This client should be assessed first because they are at risk of hypoglycemia, which is a medical emergency that can cause seizures, coma, or death if not treated promptly.

The nurse should check the client’s blood glucose level again and provide additional carbohydrates or glucose if needed.

Choice A is wrong because a client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.

The nurse should verify the client’s consent, allergies, and vital signs before the procedure, but this is not a priority over a client with low blood glucose.

Choice B is wrong because a client who received a pain medication 30 min ago for postoperative pain is likely to have improved pain relief and does not need immediate assessment.

The nurse should monitor the client’s pain level, vital signs, and respiratory status periodically, but this is not a priority over a client with low blood glucose.

Choice D is wrong because a client who has 100 mL of fluid remaining in his IV bag is not in immediate danger and can be assessed later.

The nurse should change the IV bag when it is empty or nearly empty, but this is not a priority over a client with low blood glucose.

Normal blood glucose levels are between 70 to 100 mg/dL (3.9 to 5.5 mmol/L) when fasting, and less than 140 mg/dL (7.8 mmol/L) two hours after eating. A blood glucose level below 70 mg/dL (3.9 mmol/L) is considered hypoglycemia and requires immediate treatment. Orange juice is a source of simple carbohydrates that can raise blood glucose quickly, but it may not be enough to prevent hypoglycemia in some cases.

Choice A reason:

Eating 1 g/kg of protein per day is the appropriate recommendation. When providing discharge teaching to a client with chronic kidney disease (CKD) who is receiving haemodialysis, the nurse should include the instruction to eat an appropriate amount of protein, which is usually recommended at a specific daily intake based on the client's weight.

Clients with CKD often have dietary restrictions, including limiting protein intake to reduce the workload on the kidneys. However, protein intake is still necessary for maintaining muscle mass and overall health. The recommended protein intake for clients with CKD undergoing haemodialysis is typically around 1 gram of protein per kilogram of body weight per day.

Choice B reason:

Drink at least 3 L of fluid daily. Clients receiving haemodialysis typically have fluid restrictions, as impaired kidney function can lead to fluid retention and electrolyte imbalances. The specific fluid allowance will be determined by the healthcare provider based on the client's individual needs, and it may be significantly less than 3 L per day.

Choice Doption

Take magnesium hydroxide for ingestion. Magnesium hydroxide is a laxative and antacid used to relieve constipation and heartburn. It is not typically prescribed for clients with chronic kidney disease, especially without proper evaluation of their kidney function and overall medical condition.

Choice Coption:

C. Consume foods high in potassium.

Clients with chronic kidney disease, especially that undergoing haemodialysis, often need to restrict potassium intake. Impaired kidney function can lead to the build-up of potassium in the blood, which can be harmful. Therefore, it is essential for clients with CKD to avoid or limit foods high in potassium.