After giving 6 oz of orange juice to a patient with hypoglycemia, the nurse finds that the patient's blood glucose level is 65 mg/dl. Which nursing intervention would be the most appropriate in this situation?

Giving an additional 15 g of carbohydrate

Giving 25 to 50 ml of 50% glucose IV

Administering 1 mg IM glucagon

Administering 5% to 10% dextrose infusion

Answer and Explanation

The Correct Answer is A

A. After administering a carbohydrate source (e.g., 6 oz of orange juice), the nurse should reassess the patient's blood glucose level. If the glucose is still below the target range (typically above 70 mg/dL), the next step is to give an additional 15 grams of carbohydrate to raise the blood sugar. This is a standard approach for mild to moderate hypoglycemia.
B. Giving 25 to 50 ml of 50% glucose IV is typically reserved for patients who are severely hypoglycemic and unable to swallow or are unresponsive. This method is appropriate when the patient cannot take oral glucose, but the client in this scenario is still conscious.
C. Administering 1 mg IM glucagon is used when a patient is unable to ingest glucose orally and is unresponsive or vomiting. It stimulates the liver to release stored glucose, but this is not necessary in a conscious patient who can swallow.
D. Administering a 5% to 10% dextrose infusion is typically used in more severe cases of hypoglycemia, especially when IV access is established, and the patient is unable to take oral glucose. This would not be necessary for a patient who can safely swallow.

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Correct Answer is A

Explanation

A. Shake the MDI prior to administration: This is the correct action. Shaking the MDI ensures that the medication is evenly mixed with the propellant, which is essential for delivering the correct dose. If the inhaler is not shaken, the medication may not be properly dispensed.
B. Ask the client to inhale the medication quickly for 1 second: This is incorrect. The client should inhale slowly and deeply to ensure the medication reaches the lower airways. A quick inhalation may not allow the medication to be delivered effectively, reducing its therapeutic effect.
C. Wash the MDI canister in warm water after each use: This is incorrect. The MDI canister itself should not be washed as it may damage the device. Only the mouthpiece should be cleaned according to the manufacturer's instructions. Overwashing the device can cause malfunctions.
D. Ask the client to hold their breath for 2 seconds after inhalation: This is too short. The client should hold their breath for about 10 seconds to allow the medication to fully reach the lungs and be absorbed. A brief hold, such as 2 seconds, may not be enough to maximize the medication's effectiveness.

A. Tachypnea B. Bradycardia C. Hypothermia D. Pulse deficit

Correct Answer is A

Explanation

A. Tachypnea, or rapid breathing, is a common finding in pneumonia due to hypoxia and the body's attempt to compensate for impaired gas exchange in the lungs. It is one of the hallmark signs of pneumonia.
B. Bradycardia is uncommon in pneumonia. Tachycardia (increased heart rate) is more frequently observed as the body compensates for the infection and reduced oxygenation.
C. Hypothermia is not typically associated with pneumonia; more commonly, fever (hyperthermia) is present as a sign of infection.
D. A pulse deficit is a sign of a heart condition, such as atrial fibrillation, not typically related to pneumonia.

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After giving 6 oz of orange juice to a patient with hypoglycemia, the nurse finds that the patient's blood glucose level is 65 mg/dl. Which nursing intervention would be the most appropriate in this situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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