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 C
Explanation
Prednisone is a corticosteroid medication that can increase blood glucose levels by promoting gluconeogenesis (the production of glucose from non-carbohydrate sources) and reducing glucose utilization in the body. This can lead to elevated blood sugar levels, especially in individuals with diabetes. The client's history of urinary tract infection and the use of Prednisone suggest that the infection might have triggered the development of DKA.
It's important to note that DKA can occur even when a person is taking insulin as prescribed and following their diet carefully if other factors contribute to the development of DKA, such as an underlying infection or the use of certain medications like Prednisone. The nurse should further assess the client's condition and notify the healthcare provider to initiate appropriate management for DKA.
Correct Answer is ["250"]
Explanation
To calculate the rate at which the nurse should set the IV pump in mL/hr, we need to determine the infusion rate.
The client is receiving 1 gram of antibiotic in 500 ml of fluid over 2 hours. To find the rate in mL/hr, we divide the total volume (500 ml) by the total time (2 hours):
Rate = Volume / Time Rate = 500 ml / 2 hours Rate = 250 ml/hr
Therefore, the nurse should set the IV pump at a rate of 250 mL/hr.
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