A patient is recovering from an episode of diabetic ketoacidosis and reports feeling “anxious, shaky, and sweaty.”. What should be the nurse’s initial action?

Obtain a full set of vital signs.

Administer 1 mg glucagon subcutaneously.

Administer 25 mL of 50% dextrose.

Obtain a blood glucose reading.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While obtaining a full set of vital signs is an important part of assessing a patient’s condition, it should not be the initial action in this case. The symptoms described by the patient suggest hypoglycemia, which requires immediate confirmation and treatment.

Choice B rationale

Administering 1 mg glucagon subcutaneously is not the initial action. Glucagon is used to treat severe hypoglycemia when the patient is unable to take glucose orally. However, the patient’s blood glucose level should be checked first.

Choice C rationale

Administering 25 mL of 50% dextrose is not the initial action. This treatment is used for severe hypoglycemia, but the patient’s blood glucose level should be checked first to confirm hypoglycemia.

Choice D rationale

Obtaining a blood glucose reading is the correct initial action. The symptoms described by the patient suggest hypoglycemia. Checking the blood glucose level will confirm whether the patient is hypoglycemic and needs treatment.

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Correct Answer is C

Explanation

Choice A rationale

Heparin does not actually thin the blood or make it less thick. Instead, it works by increasing the activity of antithrombin, a protein that inhibits blood clotting. This prevents new clots from forming and existing clots from growing larger.

Choice B rationale

Heparin does not dissolve clots or decrease the formation of platelets. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa, two key players in the blood clotting process.

Choice C rationale

This statement is accurate. Heparin does not thin the blood; instead, it prevents new clots from forming and existing clots from growing larger. It does this by increasing the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

Choice D rationale

Heparin does not decrease the number of platelets or make the blood flow more easily. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

A. Inject the insulin syringe at a 90-degree angle. B. Avoid the deltoid when injecting the insulin. C. Rotate injection sites correctly. D. Massage the injection site.

Correct Answer is C

Explanation

Choice A rationale

Injecting the insulin syringe at a 90-degree angle is a technique used to ensure that the insulin is delivered into the subcutaneous tissue. However, this does not specifically prevent lipodystrophy.

Choice B rationale

Avoiding the deltoid when injecting insulin is not typically a recommendation for preventing lipodystrophy. Insulin is usually injected into the fatty tissue just under the skin in the abdomen, thighs, buttocks, or upper arms.

Choice C rationale

Rotating injection sites correctly is a key strategy for preventing lipodystrophy. Lipodystrophy refers to abnormal changes in the fat tissue under the skin and can be caused by repeatedly injecting insulin into the same spot.

Choice D rationale

Massaging the injection site is not typically recommended as it can cause the insulin to be absorbed too quickly.

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A patient is recovering from an episode of diabetic ketoacidosis and reports feeling “anxious, shaky, and sweaty.”. What should be the nurse’s initial action?

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient diagnosed with deep vein thrombosis asks the nurse, “How does this blood thinner heparin work?” Which response is most accurate?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

To prevent lipodystrophy in a client receiving insulin therapy, what should the nurse instruct the client to do?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The client, on an intensified insulin regimen, consistently has a fasting blood glucose between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. What is the nurse’s interpretation of these findings?

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