The client received ten (12) units of regular insulin at 08:00. At 11:30 the unlicensed assistant personnel (UAP) tells the nurse the client has a headache and is really acting funny. Which intervention should the registered nurse implement first?
Instruct the UAP to obtain a blood glucose level
Go to the client's room and assess the client for hypoglycemia
Have the client drink 8 ounces of orange juice
Prepare to administer one ampule 50% dextrose intravenously
The Correct Answer is B
A. Instructing the UAP to obtain a blood glucose level could be useful, but the nurse should prioritize assessing the client directly.
B. Assessing the client is the first step to confirm hypoglycemia and determine the severity, allowing for appropriate intervention.
C. Administering orange juice may be appropriate after confirming hypoglycemia, but an assessment should be performed first.
D. Administering dextrose is a severe intervention used when symptoms are extreme; assessment should occur first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bright yellow urine is typical of well-hydrated individuals but is not expected after a prostatectomy.
B. Dark amber urine may indicate dehydration or concentrated urine, which is not the expected outcome post-surgery.
C. Bright red urine can indicate significant bleeding, which should be reported; however, some blood may be expected immediately after surgery.
D. Pale pink urine is a common and expected variation after a transurethral prostatectomy, indicating minor bleeding or irritation without significant risk.
Correct Answer is ["B","D"]
Explanation
A. Monitoring blood glucose levels is not directly related to managing fluid volume excess.
B. Weighing the client daily is essential for monitoring fluid retention and the effectiveness of interventions.
C. Preparing for hemodialysis is only necessary for severe fluid overload unresponsive to other treatments.
D. Restricting sodium in the diet helps prevent further fluid retention and supports management of FVE.
E. Changing IV fluids to D5W is not appropriate, as it could exacerbate fluid volume excess by increasing fluid load.
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