A Type 1 diabetic client’s blood glucose level is 50 mg/dL at 16:30. The client is alert; however, dinner will not be served until 17:15. What should be the nurse’s initial action?
Have the client drink 4 oz. of orange juice
Give the client 3 tbsp.
of sugar dissolved in 4 oz. of grape juice to drink
Monitor the client closely until dinner arrives
The Correct Answer is A
Step 1 is to understand that a blood glucose level of 50 mg/dL is considered hypoglycemic. Immediate treatment is necessary to raise the blood glucose level.
Step 2 is to follow the 15-15 rule for treating hypoglycemia, which recommends consuming 15 grams of carbohydrates and then checking blood glucose levels after 15 minutes. Four ounces of orange juice contains about 15 grams of carbohydrates and can quickly raise blood glucose levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Clients taking clopidogrel should be advised to call their healthcare provider if they notice that their stools are dark. This could be a sign of gastrointestinal bleeding, a potential side effect of clopidogrel.
Choice B rationale
Changing positions slowly to avoid dizziness is not specifically related to clopidogrel use.
Choice C rationale
While it’s generally advised to avoid taking other blood thinners while on clopidogrel, aspirin is sometimes prescribed together with clopidogrel under the supervision of a healthcare provider.
Choice D rationale
There is no specific recommendation to take clopidogrel with orange juice for it to be more effective.
Correct Answer is B
Explanation
Choice A rationale
While understanding the recommended diabetic diet is important for managing type 1 diabetes, it is not the immediate priority for a client who has received no instruction on diabetes management. Without insulin, a person with type 1 diabetes can develop life- threatening diabetic ketoacidosis, regardless of their diet.
Choice B rationale
Administration of insulin is the immediate priority for a client newly diagnosed with type 1 diabetes. In type 1 diabetes, the body does not produce insulin, a hormone that regulates blood sugar levels. Without insulin, blood sugar levels can become dangerously high, leading to diabetic ketoacidosis, a serious condition that requires emergency medical treatment.
Choice C rationale
While exercise is an important part of managing diabetes, it is not the immediate priority for a client newly diagnosed with type 1 diabetes who has received no instruction on diabetes management. Exercise can help regulate blood sugar levels, but without insulin, exercise alone is not sufficient to prevent diabetic ketoacidosis.
Choice D rationale
Urine testing for ketones is an important part of managing type 1 diabetes, especially during illness or stress, when ketone levels can rise quickly. However, it is not the immediate priority for a client newly diagnosed with type 1 diabetes who has received no instruction on diabetes management.
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