At 1630 a Type I diabetic client's blood glucose level is 50 mg/dl. The client is alert; however, dinner will not be served until 1715. The nurse's initial action should be to:

monitor the client closely until dinner arrives.

have the client drink 4 oz. of orange juice.

give the client 3 tbsp. of sugar dissolved in 4 oz. of grape juice to drink.

have the client dissolve a small piece of hard candy in their mouth.

Answer and Explanation

The Correct Answer is B

A.   While monitoring is important, doing nothing to address the hypoglycemia is not safe. A blood glucose level of 50 mg/dL is low and requires immediate intervention to prevent more severe hypoglycemic symptoms or complications.
B.   This is a suitable option for treating mild to moderate hypoglycemia. Orange juice is a quick source of carbohydrates and can effectively raise blood glucose levels. Four ounces typically provides enough sugar to help increase the client's blood glucose level before dinner is served.
C.   While this option would also effectively raise blood glucose, it is more complicated than simply having the client drink orange juice. The sugar may take additional time to dissolve, and grape juice may not be readily available. In an acute situation, simplicity and speed are key.
D.   While hard candy can raise blood glucose levels, it may take longer to dissolve and provide sufficient glucose quickly compared to liquid sources like orange juice or grape juice. Additionally, the amount of candy needed may not be clear, making this a less reliable option in an urgent situation.

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Correct Answer is C

Explanation

A. While D5 0.45% NS contains dextrose, it is not suitable as an initial treatment in HHS because patients are often hyperglycemic. Starting with dextrose can worsen hyperglycemia.
B. Although providing oxygen may be appropriate if the client shows signs of respiratory distress or hypoxia, it is not the first-line treatment for HHS. The immediate priority is addressing dehydration and hyperglycemia.
C. The initial therapy for HHS involves administering IV fluids, typically starting with 0.9% saline (normal saline). This helps to rapidly rehydrate the client and dilute the high glucose levels in the blood. Correcting dehydration is critical in HHS management.
D. Glucagon is typically used to treat hypoglycemia, not hyperglycemia. In HHS, the patient is hyperglycemic, so administering glucagon would not be appropriate.

A. take vital signs. B. administer 1 mg glucagon subcutaneously. C. obtain a blood glucose reading. D. notify the physician.

Correct Answer is C

Explanation

A. While taking vital signs can provide useful information about the client's overall condition, it does not address the immediate concern of potential hypoglycemia. The priority is to assess blood glucose levels directly.
B. Glucagon can be administered in cases of severe hypoglycemia where the patient is unable to ingest glucose orally. However, before administering glucagon, the nurse should first check the blood glucose level to confirm hypoglycemia.
C. Checking the blood glucose level will provide immediate information about whether the client is experiencing hypoglycemia. If the blood glucose is low, appropriate treatment (such as administering glucose or a fast-acting carbohydrate) can be initiated. If it’s within normal limits, other causes for the symptoms can be explored.
D. While it may be necessary to notify the physician depending on the outcome of the blood glucose reading or if the client’s condition worsens, it is not the first action. Immediate assessment of the blood glucose level is essential to determine the correct course of action.

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At 1630 a Type I diabetic client's blood glucose level is 50 mg/dl. The client is alert; however, dinner will not be served until 1715. The nurse's initial action should be to:

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