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The nurse notes a client with a prescription for glipizide is confused, diaphoretic, and tachycardic. What is the nurse’s priority assessment?

A.

Blood glucose

B.

Apical heart rate

C.

INR level

D.

Last bowel movement

Answer and Explanation

The Correct Answer is A

Choice A reason: This choice is correct because blood glucose is the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. Glipizide is a medicine that lowers blood sugar levels in the body. It can cause side effects such as anxiety, diarrhea, nausea, and low blood sugar. Low blood sugar (hypoglycemia) can cause confusion, sweating, fast heart rate, dizziness, hunger, and seizures. The nurse should check the client's blood glucose level and treat hypoglycemia as soon as possible. 

Choice B reason: This choice is incorrect because apical heart rate is not the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. Apical heart rate is the number of heartbeats per minute that can be heard at the apex of the heart. It can be affected by many factors, such as age, activity, stress, and medication. Tachycardia is a condition where the heart beats faster than normal, which can be a sign of low blood sugar, dehydration, infection, or heart problems. The nurse should check the apical heart rate after assessing and treating the blood glucose level. 

Choice C reason: This choice is incorrect because INR level is not the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. INR stands for international normalized ratio, which is a measure of how long it takes the blood to clot. It is used to monitor the effect of anticoagulant drugs, such as warfarin, that prevent blood clots. Glipizide does not affect the INR level, and the client's symptoms are not related to bleeding or clotting. The nurse should check the INR level only if the client is taking anticoagulant drugs and has signs of bleeding or clotting. 

Choice D reason: This choice is incorrect because the last bowel movement is not the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. The last bowel movement is the time and nature of the client's most recent defecation. It can be affected by many factors, such as diet, fluid intake, activity, medication, and bowel habits. Glipizide can cause diarrhea or constipation, which can affect the frequency and consistency of the bowel movement. The nurse should check the last bowel movement after assessing and treating the blood glucose level.


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Related Questions

Correct Answer is ["1.1"]

Explanation

To calculate the amount of cefazolin that the nurse should add to the 50 mL of 0.9% sodium chloride, we can use the following steps:

Calculate the amount of cefazolin needed to prepare the solution:

  • The concentration to be achieved is 225 mg/mL.
  • The required dose is 250 mg.

Calculate the volume of cefazolin needed:

  • 250 mg ÷ 225 mg/mL = 1.111... mL
  • Rounded to the nearest tenth, the nurse should add 1.1 mL of cefazolin to the 50 mL of 0.9% sodium chloride.

Therefore, the nurse should add 1.1 mL of cefazolin to the 50 mL of 0.9% sodium chloride to prepare the solution for IV administration.

Correct Answer is ["25"]

Explanation

To calculate the IV flow rate in drops per minute (gtt/min) for the administration of clindamycin, we can follow these steps:

First, we need to determine the total number of minutes for the infusion, which is given as 1 hour:

1 hour × 60 minutes/hour = 60 minutes

Next, we calculate the total number of drops needed for the infusion:

The total volume to be infused is 100 mL.

The drop factor is 15 gtt/mL.

100 mL × 15 gtt/mL = 1500 gtt

Calculate the IV flow rate in drops per minute:

1500 gtt ÷ 60 min = 25 gtt/min

Rounding to the nearest whole number, the nurse should set the IV flow rate to deliver 25 gtt/min.

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