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.
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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Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is B
Explanation
Choice A rationale
Febrile and shallow respirations are not typically associated with uncontrolled diabetes mellitus and ketoacidosis. These symptoms could be indicative of a different medical condition.
Choice B rationale
An increased rate and depth of respiration, also known as Kussmaul breathing, is a common clinical manifestation in patients with uncontrolled diabetes mellitus and ketoacidosis.
Choice C rationale
Weakness and weight gain are not typically associated with uncontrolled diabetes mellitus and ketoacidosis. These symptoms could be indicative of a different medical condition.
Choice D rationale
Extremity tremors followed by seizure activity are not typically associated with uncontrolled diabetes mellitus and ketoacidosis. These symptoms could be indicative of a different medical condition.
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