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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The letter "M" in cancer staging refers to metastasis, or whether cancer has spread to other parts of the body.
B. "D" is not part of the TNM staging system for cancer.
C. "T" in the TNM staging system refers to the size of the primary tumor and its extent in the tissue.
D. "N" refers to the extent of regional lymph node involvement but not metastasis to distant organs.

A. Hypertension B. Unequal pupils C. Confusion D. Tympany upon chest percussion

Correct Answer is C

Explanation

A. Hypertension is not typically associated with pneumonia, especially in older adults. Pneumonia can lead to hypotension or sepsis, but not usually hypertension.
B. Unequal pupils are not a typical finding associated with pneumonia. This could suggest a neurological issue or a possible eye problem, not a respiratory infection.
C. Confusion is a common sign of pneumonia in older adults, especially in the elderly, who may present with altered mental status due to hypoxia, infection, or dehydration. Delirium or confusion is a common manifestation of pneumonia in this population.
D. Tympany on chest percussion suggests air in the abdominal cavity, not in the lungs, and is not typically associated with pneumonia. Pneumonia is more likely to present with dullness upon percussion due to consolidation in the lungs.

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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?

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