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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hirsutism, or excessive hair growth, is more commonly associated with conditions such as polycystic ovary syndrome (PCOS) or Cushing’s syndrome, rather than Addison’s disease.
B. Hyperpigmentation is a characteristic sign of Addison’s disease. Due to insufficient cortisol production in the adrenal glands, there is an increase in melanocyte-stimulating hormone (MSH), which leads to darkening of the skin, particularly in areas exposed to friction like elbows, knees, and the face.
C. Purple striations are a common finding in Cushing’s syndrome, which results from excessive cortisol production. They are not typically seen in Addison's disease.
D. Intention tremors are more commonly associated with neurological conditions, such as Parkinson’s disease, rather than Addison’s disease, which primarily affects the adrenal glands.
Correct Answer is B
Explanation
A. Have the client refrain from talking for 24 hr.: This is unnecessary; the client may talk once the effects of the local anesthetic wear off, typically within an hour or two after the procedure.
B. Withhold food and liquids until the client's gag reflex returns: This is the most important action to prevent aspiration. After a bronchoscopy, the throat is anesthetized, and eating or drinking before the gag reflex returns increases the risk of aspiration.
C. Irrigate the client's throat every 4 hr.: This is not a routine post-procedure intervention and could be uncomfortable for the client.
D. Suction the client's oropharynx frequently: Suctioning should only be performed if the client has difficulty clearing secretions. There is no routine need for frequent suctioning after a bronchoscopy unless clinically indicated.
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