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 C

Explanation

A. "It is caused by the lack of production of insulin by the pancreas.": This is incorrect. The lack of insulin production causes diabetes mellitus, not Addison’s disease. Addison’s disease results from insufficient production of adrenal hormones, particularly aldosterone and cortisol.
B. "It is caused by the overproduction of parathormone by the parathyroid gland.": This is incorrect. Parathormone is produced by the parathyroid glands and regulates calcium balance, but overproduction of parathormone leads to conditions such as hyperparathyroidism, not Addison’s disease.
C. "It is caused by the lack of production of aldosterone by the adrenal gland.": This is correct. Addison’s disease, also known as primary adrenal insufficiency, is caused by the inability of the adrenal glands to produce sufficient aldosterone and cortisol, two critical hormones. Aldosterone helps regulate sodium and potassium balance, and cortisol helps the body respond to stress.
D. "It is caused by the overproduction of growth hormone by the pituitary gland.": This is incorrect. Overproduction of growth hormone causes acromegaly or gigantism, not Addison’s disease. Addison’s disease results from adrenal insufficiency, not pituitary gland dysfunction.

A. The client exhales as the medication is released from the inhaler B. The client takes a quick inhalation while releasing the medication from the inhaler C. The client holds his breath for 10 seconds after inhaling the medication D. The client waits 10 min between inhalations

Correct Answer is C

Explanation

A. The client exhales as the medication is released from the inhaler: This is incorrect. The client should inhale deeply while activating the inhaler. Exhaling before inhaling will reduce the effectiveness of the medication.
B. The client takes a quick inhalation while releasing the medication from the inhaler: This is incorrect. The client should inhale slowly and deeply to allow the medication to reach the lungs effectively. A quick inhalation may result in less medication being delivered to the lungs.
C. The client holds his breath for 10 seconds after inhaling the medication: This is the correct action. Holding the breath allows the medication to settle in the lungs, enhancing its therapeutic effect.
D. The client waits 10 min between inhalations: This is not necessary unless instructed by the healthcare provider. Most guidelines suggest waiting 1 to 2 minutes between inhalations of the same medication.

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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

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