The nurse is caring for a client with a blood glucose reading of 620 mg/dL. The nurse would expect all of the following interventions except which?
Antihypertensive medication
Fluid replacement
Potassium laboratory monitoring
Insulin IV infusion
The Correct Answer is A
A. Antihypertensive medication is not a priority intervention for a client with a blood glucose level of 620 mg/dL, which indicates hyperglycemia, likely due to diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). The focus should be on correcting the hyperglycemia and preventing complications like dehydration or electrolyte imbalances.
B. Fluid replacement is essential to treat dehydration caused by hyperglycemia, as high blood glucose levels cause osmotic diuresis.
C. Potassium laboratory monitoring is crucial because insulin treatment can shift potassium into cells, potentially causing hypokalemia, so monitoring is necessary during treatment.
D. Insulin IV infusion is necessary to lower the blood glucose level in clients with severe hyperglycemia, such as in DKA or HHS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["44"]
Explanation
Calculate the flow rate in mL/hour: 400 mL / 3 hours = 133.33 mL/hour (approximately)
Convert the flow rate to mL/minute: 133.33 mL/hour / 60 minutes/hour = 2.22 mL/minute (approximately)
Calculate the drops per minute: 2.22 mL/minute 20 gtt/mL = 44.4 gtt/minute
Round to the nearest whole number: 44 gtt/minute
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
- Fall precautions: The client is disoriented, which significantly increases their risk of falls. Addressing this is the immediate priority for client safety.
- Antibiotic therapy: The client is febrile and has foul-smelling urine, indicating a likely urinary tract infection (UTI). While important, initiating antibiotic therapy is secondary to ensuring the client's immediate safety from falls.
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