The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take?
Reference Ranges
- Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
Collect a blood sample for hemoglobin Alc.
Give the client a glass of orange juice.
Notify the healthcare provider.
Assess client for polyuria and polyphagia.
The Correct Answer is B
In this situation, the client has a fingerstick glucose level of 35 mg/dL (1.94 mmol/L) and is alert but diaphoretic. The charge nurse should take the following action:
Give the client a glass of orange juice.
A glucose level of 35 mg/dL (1.94 mmol/L) is considered significantly low (hypoglycemia), and the client's symptoms of diaphoresis indicate that the low glucose level is likely causing the symptoms. Providing the client with a glass of orange juice or another source of fast-acting carbohydrate is appropriate to quickly raise the blood sugar level and alleviate the symptoms of hypoglycemia.
Collecting a blood sample for hemoglobin A1c (HbA1c) is not necessary in this acute situation. HbA1c reflects the average blood glucose level over the past 2-3 months and is used to assess long-term glycemic control in clients with diabetes. It does not provide immediate information or guide immediate interventions for acute hypoglycemia.
Notifying the healthcare provider is not the first action to take in this situation. The client's low glucose level can be promptly addressed by administering a source of fast-acting carbohydrate, such as orange juice. If the client's symptoms persist or worsen despite appropriate intervention, or if there are other concerning factors, then notifying the healthcare provider would be appropriate.
Assessing the client for polyuria (excessive urination) and polyphagia (excessive hunger) is important in the overall management of diabetes, but it is not the immediate action to take in this acute situation of hypoglycemia. The priority at this time is to address the low blood sugar level and relieve the client's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The ability to effectively communicate and provide accurate information can be impacted by external factors such as noise, distractions, or an unfamiliar environment. By assessing the surroundings, the nurse can identify and address any potential barriers to communication.
Once the nurse has addressed any environmental factors that may be hindering communication, they can proceed with other strategies to facilitate the health history assessment. This may include providing a printed healthcare assessment form to assist the client in organizing their thoughts or deferring the assessment until the client is less anxious.
Asking the family member to answer the questions should be considered if the client is unable to provide accurate information or is cognitively impaired. However, it is important to first address any environmental factors and attempt to engage the client directly in the assessment process.
Correct Answer is B
Explanation
A functional assessment is an evaluation of an individual's ability to perform activities of daily living (ADLs), which includes tasks such as bathing, dressing, toileting, eating, and mobility. Falls are a common and significant issue among older adults and are a leading cause of injury and hospitalization. Therefore, it is important to assess the client's risk of falling and inquire about any recent falls to develop an appropriate plan of care to prevent falls.
Encouraging the client to lie as still as possible during the assessment is not appropriate as it may not provide an accurate evaluation of the client's ability to perform ADLs.
Additionally, it is important to assess the client's functional status in a way that is safe and comfortable for them.
Assisting the client with values clarification about end-of-life care options is not appropriate during a functional assessment as it is not directly related to the client's ability to perform ADLs.
Asking the client how often episodes of sundowning are experienced is not appropriate during a functional assessment as sundowning is a symptom of dementia and is not directly related to the client's ability to perform ADLs.
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