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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Increasing the nighttime insulin glargine dose may exacerbate the Somogyi effect, a phenomenon where the blood sugar level drops too low overnight, causing a rebound high blood sugar level in the morning.
Choice B rationale
Consuming a snack at bedtime can help prevent the blood sugar level from dropping too low overnight, thus preventing the Somogyi effect.
Choice C rationale
Checking the morning cortisol level is not directly related to managing the Somogyi effect.
Choice D rationale
Checking the glucose level at 2 a.m. and 8 a.m. can help identify the Somogyi effect, but it does not prevent it.
Correct Answer is A
Explanation
Choice A rationale
When a patient is informed about a serious diagnosis like breast cancer and the need for a mastectomy, it is common for them to experience a range of emotions, including sadness, fear, and anxiety. As a nurse, providing emotional support and creating a safe space for the patient to express their feelings is crucial. Offering to be there for the patient if they want to talk acknowledges their emotional distress and provides comfort.
Choice B rationale
Asking the patient why they are upset may come across as insensitive or dismissive. The patient has just received a life-changing diagnosis, and their emotional reaction is completely normal and expected. It’s important to provide support and empathy rather than questioning their feelings.
Choice C rationale
Telling the patient that everything will be alright and there is no need to cry may seem comforting, but it can actually invalidate the patient’s feelings. It’s important to acknowledge the patient’s emotions and allow them to express their feelings without judgment.
Choice D rationale
Telling the patient that they will recover may be seen as providing false reassurance. While it’s important to maintain hope, it’s also crucial to be honest and realistic with the patient about their diagnosis and treatment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.