The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication?
Ask the pharmacist to add the Dextrose to a TPN solution.
Mix the Dextrose in a 50 mL piggyback for a total volume of 100 mL.
Push the undiluted Dextrose slowly through the currently infusing IV.
Dilute the Dextrose in one liter of 0.9% Normal Saline solution.
The Correct Answer is C
Choice C is correct because pushing the undiluted Dextrose slowly through the currently infusing IV is the best way to administer the medication for a client with insulin shock. Insulin shock is a condition in which the blood glucose level drops too low due to excess insulin or insufficient food intake. This can cause symptoms such as confusion, sweating, tremors, or loss of consciousness. The nurse should administer 50% Dextrose IV as a bolus injection to raise the blood glucose level quickly and prevent brain damage.
Choice A is incorrect because asking the pharmacist to add the Dextrose to a TPN solution is not appropriate for a client with insulin shock. TPN stands for total parenteral nutrition, which is a type of intravenous feeding that provides all the nutrients needed by the body. TPN solutions contain dextrose, amino acids, lipids, vitamins, minerals, and electrolytes in specific concentrations and ratios. Adding extra dextrose to a TPN solution can alter its composition and cause complications such as hyperglycemia or fluid overload.
Choice B is incorrect because mixing the Dextrose in a 50 mL piggyback for a total volume of 100 mL is not effective for a client with insulin shock. A piggyback is a type of intravenous infusion that delivers medication through a secondary tubing attached to the primary tubing of another solution. Mixing the Dextrose in a piggyback can dilute its concentration and reduce its potency. It can also delay its delivery and onset of action.
Choice D is incorrect because diluting the Dextrose in one liter of 0.9% Normal Saline solution is not safe for a client with insulin shock. Normal Saline is a type of intravenous fluid that contains sodium chloride in isotonic concentration. Diluting the Dextrose in one liter of Normal Saline can lower its concentration and increase its volume significantly. This can cause complications such as hypoglycemia or fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A is correct because a distended bladder can displace the uterus and prevent it from contracting properly, leading to increased bleeding and risk of infection. The nurse should check for a distended bladder and assist the client to empty it if needed.
Choice B is incorrect because reviewing the hemoglobin is not a priority action. The hemoglobin may not reflect the current blood loss and may be done later.
Choice C is incorrect because massaging the uterus is not necessary if it is firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D is incorrect because increasing intravenous infusion is not a priority action. The client may not need additional fluids if the bleeding is moderate and the vital signs are stable.
Correct Answer is C
Explanation
Choice A reason: Reminding the UAP to apply a fitted respirator mask before entering the client's room is not a necessary action for the nurse to take. A respirator mask is a type of personal protective equipment (PPE. that filters out airborne particles and droplets that may contain infectious agents. A respirator mask is required for clients who have or are suspected of having airborne diseases, such as tuberculosis, measles, or chickenpox. Influenza is a respiratory disease that is transmitted by droplet contact, not by airborne contact.
Choice B reason: Instructing the UAP to notify the nurse of any changes in the client's respiratory status is not a specific action for the nurse to take. Respiratory status is an assessment of the client's breathing pattern, rate, depth, effort, and oxygen saturation. Respiratory status can be affected by various factors, such as infection, inflammation, obstruction, or injury. The nurse should monitor the client's respiratory status regularly and teach the UAP to report any signs or symptoms of respiratory distress, such as dyspnea, cyanosis, wheezes, or cough.
Choice D reason: Assigning the UAP to provide care for another client and assuming full care of the client is not a feasible action for the nurse to take. The nurse should delegate tasks according to the scope of practice, competency, and availability of staff. The nurse should not reassign staff without a valid reason or without consulting with other team members. The nurse should also not assume full care of a client unless it is necessary or appropriate. The nurse should supervise and evaluate the UAP's performance and provide feedback and guidance.
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