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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

The client diagnosed with peripheral arterial disease has impaired tissue integrity related to ischemic tissue of the legs and feet. This condition is often caused by factors such as physical trauma, thermal factors, chemical injury, infection, nutritional imbalances, fluid imbalances, and altered circulation. The most appropriate outcome to include in the care plan would be for the client to verbalize an understanding of appropriate foot care measures by discharge. This is because maintaining skin integrity and providing effective wound care are crucial aspects of managing this condition. By understanding and implementing appropriate foot care measures, the client can help prevent further tissue damage, promote healing, and improve their overall quality of life.

Choice B rationale

While taking anti-platelet medications can be an important part of managing peripheral arterial disease, it may not directly address the nursing problem of impaired tissue integrity. Anti-platelet medications can help prevent blood clots and improve blood flow, but they do not directly promote wound healing or tissue regeneration.

Choice C rationale

Discussing exercises that promote healing of wounds can be beneficial for the client. However, it’s important to note that exercises should be appropriate for the client’s condition and overall health status. Overexertion or inappropriate exercises could potentially exacerbate the condition and further impair tissue integrity.

Choice D rationale

Recognizing the need for an amputation in the near future can be a realistic outcome for some clients with severe peripheral arterial disease. However, this is typically considered a last resort when all other treatment options have failed. It’s also a drastic measure that can significantly impact the client’s quality of life.

A. Rotate sites when injecting insulin glargine. B. There is no peak of action for this insulin, which reduces the risk of hypoglycemia. C. Food should be consumed within 30 minutes after injection. D. Check for microalbuminuria if blood glucose levels are above 280 mg/dL.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Rotating injection sites when administering insulin glargine is important to prevent lipodystrophy, a condition that can affect insulin absorption.

Choice B rationale

Insulin glargine has no peak of action, which reduces the risk of hypoglycemia. This is a key feature of long-acting insulins like glargine.

Choice C rationale

Food does not need to be consumed within 30 minutes after injection of insulin glargine. This is a characteristic of rapid-acting insulins, not long-acting insulins like glargine.

Choice D rationale

Checking for microalbuminuria if blood glucose levels are above 280 mg/dL is a good practice. Microalbuminuria can be an early sign of kidney damage, which can occur with poorly controlled diabetes.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with peripheral arterial disease has the nursing problem of Impaired Tissue Integrity related to ischemic tissue of the legs and feet. What is an expected outcome to include in the care plan?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is discharging a client who was just prescribed insulin glargine daily at 2000. Which of the following should be included in the teaching? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse receives an order to administer cefazolin to a client diagnosed with a urinary tract infection. The nurse withholds the medication and notifies the health care provider because the client:

A client has been taking glipizide for 6 months and reports to the nurse that their urine has become darker since starting the medication. What should be the nurse’s initial action?

The physician has just informed a patient that they have breast cancer and will require a mastectomy. The nurse finds that the patient is crying. Which response by the nurse is most appropriate?

A Type 1 diabetic client with a morning (fasting) glucose of 260 mg/dL has been diagnosed with the Somogyi effect from insulin administration. What intervention should the nurse anticipate including in the plan of care?

The nurse is educating a client who has been newly prescribed acarbose in addition to repaglinide for the treatment of Type 2 diabetes. Which statement made by the client indicates that the teaching has been effective?

The nurse is evaluating the patient’s response to antibiotic therapy. Which data would indicate that the medication has been effective?

A patient has returned to the unit following a peripheral artery angiogram with a stent insertion. Four hours post-procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cold and dusky. What should be the nurse’s immediate action?