The nurse is checking the blood glucose of a client and has a reading of 48. The client is not easily awakened and only responds with a groan. What will the nurse administer to raise the blood glucose level?

Orange juice.

Glucagon.

Cortisone.

Intravenous dextrose solution.

Answer and Explanation

The Correct Answer is D

A blood glucose reading of 48 is considered low and requires immediate intervention to raise the client's blood sugar. Intravenous dextrose solution is the fastest way to raise blood sugar levels in an unconscious client. Glucagon and cortisone can also be used to raise blood sugar levels, but they are not the first-line treatment for hypoglycemia.

Choice A, orange juice, is not appropriate for an unconscious client as they cannot swallow or drink.

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Correct Answer is B

Explanation

In the Rinne test, the nurse first places a tuning fork on the mastoid process behind the ear, and when the client states that the sound is no longer heard, the tuning fork is placed beside the ear. This test is done to compare bone conduction with air conduction. When sound is no longer heard via bone conduction, the sound will still be heard via air conduction.

Choice A is incorrect because it describes the Weber test, not the Rinne test.

Choice C is incorrect because it is not a standard hearing test.

Choice D is incorrect because it describes the Whisper test, which is also used to test for hearing loss.

A. Provide instruction on blood-thinning medication. B. Assess the client for the ability to ambulate independently. C. Include the client in planning care and setting goals. D. Praise the client when using adaptive equipment.

Correct Answer is B

Explanation

Assess the client for the ability to ambulate independently. The highest priority nursing intervention for a client admitted to a neurologic rehabilitation unit following a cerebrovascular accident is to assess the client's ability to ambulate independently. This assessment will help the nurse determine the level of assistance required and develop an appropriate care plan.

Option A. Providing instruction on blood-thinning medication is not the highest priority as it can be done later when the client's ambulation status is stable.

Option C. Including the client in the planning of care and setting of goals is important but not the highest priority in this situation as it can be done after assessing the client's ambulation status.

Option D. Praise the client when using adaptive equipment, is not the highest priority as the client's ambulation status is more important at this point.

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The nurse is checking the blood glucose of a client and has a reading of 48. The client is not easily awakened and only responds with a groan. What will the nurse administer to raise the blood glucose level?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is undergoing a tuning fork test to assess for hearing conduction. The nurse performs a Rinne test. How will this test be performed?

Correct Answer is B

Explanation

The nurse is planning care for a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of the highest priority?

Correct Answer is B

Explanation

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