After a change-of-shift report, which client should the nurse assess first?
A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute abdominal pain
A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL
A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL
A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Dumping syndrome is a common complication after Gastric Bypass surgery, where food moves too quickly from the stomach to the small intestine. It occurs when the undigested contents of the stomach are "dumped" rapidly into the small intestine, leading to symptoms such as nausea, vomiting, abdominal cramps, diarrhea, lightheadedness, and sweating.
To manage dumping syndrome, it is important for the client to avoid foods and beverages that are high in sugar and carbohydrates. Consuming these types of foods can trigger rapid gastric emptying and exacerbate the symptoms. Instead, the client should focus on a well-balanced diet that includes lean proteins, healthy fats, and complex carbohydrates.
Correct Answer is B
Explanation
A likely cause of a low sodium level (hyponatremia) of 128 mEq/L is the administration of hypotonic IV fluids. Hypotonic IV fluids have a lower concentration of solutes compared to the body's fluids, which can lead to dilutional hyponatremia. When these fluids are administered, they can cause water to move into the cells, diluting the sodium concentration in the bloodstream.
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