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 D
Explanation
A. Glucocorticoid medications are not used to treat DKA. In fact, glucocorticoids can increase blood glucose levels and exacerbate hyperglycemia.
B. Dextrose 5% in 0.45% sodium chloride is not appropriate for the initial treatment of DKA. Initially, IV fluids containing normal saline (0.9% sodium chloride) are used to correct dehydration and restore electrolyte balance.
C. Oral hypoglycemic medications are not effective in DKA, as it is a serious acute complication of diabetes that requires insulin therapy and IV fluids, not oral medications.
D. 0.9% sodium chloride IV bolus is the first-line treatment for DKA to rehydrate the patient, correct electrolyte imbalances, and dilute the high blood glucose level. After stabilization, insulin therapy is also introduced.
Correct Answer is B
Explanation
A. While tissue integrity is important, the primary concern immediately postoperatively for a patient who has undergone a partial laryngectomy is ensuring that the airway is open and clear.
B. Airway patency should be assessed first because this surgery involves the upper airway structures, and complications such as obstruction, swelling, or bleeding could compromise the airway and lead to respiratory distress.
C. Pain severity should be assessed as part of routine care, but airway patency takes precedence to prevent respiratory complications.
D. Wound drainage should be monitored but does not take priority over airway assessment in the immediate postoperative period.
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