The nurse is caring for a patient with type 2 diabetes who reports diaphoresis and palpitations. A blood glucose check reveals a level of 55 mg/dL. What is the nurse's immediate intervention?

Recheck blood glucose immediately.

Provide 15 grams of fast-acting carbohydrates.

Administer 1 mg of glucagon intramuscularly.

Prepare an insulin subcutaneous injection.

Answer and Explanation

The Correct Answer is B

Choice A reason: Rechecking blood glucose immediately is not the appropriate immediate intervention when a patient shows signs of hypoglycaemia with a blood glucose level of 55 mg/dL. Immediate treatment is needed to raise the blood glucose level to prevent further complications.

Choice B reason: Providing 15 grams of fast-acting carbohydrates is the immediate intervention for a patient with hypoglycaemia. Fast-acting carbohydrates such as glucose tablets, juice, or regular soda can quickly raise blood glucose levels. This intervention addresses the immediate need to correct hypoglycaemia symptoms such as diaphoresis and palpitations.

Choice C reason: Administering 1 mg of glucagon intramuscularly is typically reserved for severe hypoglycaemia when the patient is unconscious or unable to ingest carbohydrates. In this scenario, the patient is conscious and able to consume fast-acting carbohydrates.

Choice D reason: Preparing an insulin subcutaneous injection is not appropriate for treating hypoglycaemia. Insulin lowers blood glucose levels and would worsen the patient's hypoglycaemic state.

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Correct Answer is B

Explanation

Choice A reason:

Normal blood pressure may indicate improved hydration, but deep respirations (often seen in metabolic acidosis or DKA) suggest that the patient is still experiencing distress. This combination does not reliably signal effective treatment for HHS.

Choice B reason:

Increased alertness shows that the patient’s mental status is improving, reflecting better cerebral perfusion and hydration.
A normal heart rhythm indicates that potassium levels are stable (thanks to the potassium chloride in the IV fluids) and that the insulin therapy is not causing dangerous shifts.
Together, these findings are the best indicators that the treatment is effective.

Choice C reason:

A high urine specific gravity reveals that the urine is still concentrated, which means dehydration persists.
Although the temperature is normal, the continued dehydration is not consistent with effective treatment of HHS.

Choice D reason:

A blood glucose of 250 mg/dL suggests that hyperglycemia is being corrected; however, persistent disorientation indicates that the patient’s mental status has not improved, meaning that the treatment has not fully resolved the critical aspects of HHS.

Thus, Choice B (Increased alertness, normal heart rhythm) is the best indicator of effective treatment.

A. Foot ulcers and delayed wound healing B. Stroke prevention and cardiac health C. Retinopathy and nephropathy D. Hypertension management and cholesterol control

Correct Answer is C

Explanation

Choice A reason: Foot ulcers and delayed wound healing are related to diabetes but are considered macrovascular complications. Microvascular complications specifically refer to damage to small blood vessels.

Choice B reason: Stroke prevention and cardiac health are important but are related to macrovascular complications of diabetes. The focus here is on microvascular complications.

Choice C reason: Retinopathy and nephropathy are microvascular complications of diabetes. These conditions result from damage to small blood vessels in the eyes and kidneys, respectively. Diabetic retinopathy can lead to vision loss, while diabetic nephropathy can lead to kidney failure. It is important to monitor for these complications and manage blood glucose levels to prevent or slow their progression.

Choice D reason: Hypertension management and cholesterol control are important for overall cardiovascular health but are related to macrovascular complications. The discussion should focus on microvascular complications specific to diabetes.

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The nurse is caring for a patient with type 2 diabetes who reports diaphoresis and palpitations. A blood glucose check reveals a level of 55 mg/dL. What is the nurse's immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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