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After a change-of-shift report, which client should the nurse assess first?

A.

A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute abdominal pain

B.

A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL

C.

A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL

D.

A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%

Answer and Explanation

The Correct Answer is B

A blood glucose level of 40 mg/dL indicates severe hypoglycemia, which is a medical emergency requiring immediate attention. Hypoglycemia can lead to confusion, altered mental status, seizures, and loss of consciousness if not treated promptly. Therefore, it is crucial to assess and intervene quickly to raise the patient's blood glucose level to a safe range.

While the other clients mentioned also require attention and appropriate care, the severity and immediate risk associated with severe hypoglycemia make it the priority situation. The nurse should initiate appropriate treatment for hypoglycemia, such as administering glucose or glucagon, and closely monitor the patient's response.


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Related Questions

Correct Answer is B

Explanation

IBD, which includes conditions such as Crohn's disease and ulcerative colitis, is characterized by chronic inflammation of the gastrointestinal tract. The symptoms can vary depending on the type and severity of the disease, but common symptoms in children with IBD include:

  1. Children with IBD often experience increased frequency of bowel movements, which may be loose or watery. This is often accompanied by urgency and a sense of incomplete evacuation.
  2. Chronic inflammation in the gastrointestinal tract can interfere with nutrient absorption, leading to poor appetite, decreased intake, and subsequent weight loss. In severe cases, malnutrition may occur.
  3. Inflammatory processes in the intestines can lead to increased motility and peristalsis, resulting in hyperactive bowel sounds.

Correct Answer is D

Explanation

These symptoms suggest the possibility of deep vein thrombosis (DVT), which is a potentially serious complication following surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the lower extremities. The symptoms of a swollen, warm, and painful calf can indicate the presence of a DVT.

DVT is a medical emergency that requires immediate attention and intervention to prevent further complications such as a pulmonary embolism (where the blood clot travels to the lungs). Prompt evaluation and treatment, such as anticoagulant therapy, are necessary to prevent complications

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