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 ["B","D"]
Explanation
A) Incorrect- This behavior is not safe for maintaining balance. Bending from the waist can increase the risk of falling. Clients should bend at the knees and use proper body mechanics to pick up objects from the floor.
B) Correct- Widening the stance provides a broader base of support, which can help improve balance and stability while working near the sink. This is a safe behavior to maintain balance.
C) Incorrect- Locking the knees while standing can lead to instability and decreased balance. It is recommended to keep the knees slightly flexed to maintain better balance.
D) Correct- Bringing a heavy object close to the body before lifting minimizes strain on the back and helps maintain balance. This is a safe behavior when lifting objects.
E) Incorrect- Leaning forward to pull an object from a high shelf can disrupt the center of balance and increase the risk of falling. It's important to use a step stool or ask for assistance when reaching for items on high shelves.
Correct Answer is D
Explanation
Itraconazole is an antifungal medication used to treat a variety of fungal infections. Antacids, which are used to treat heartburn and acid reflux, can decrease the absorption of itraconazole in the body. Therefore, it is important to instruct the client to avoid taking itraconazole with antacids. If the client needs to take an antacid, it should be taken at least 2 hours before or after taking itraconazole.
Reporting any difficulty with breathing is important as it can be a sign of an allergic reaction to the medication. Monitoring for changes in stool color is important as it can be an indication of liver dysfunction, which is a potential side effect of itraconazole.
Avoiding the consumption of grapefruit juice is important as it can increase the level of itraconazole in the body, which can increase the risk of side effects.
In summary, the client should be instructed to avoid taking itraconazole with antacids and to take any antacid at least 2 hours before or after taking itraconazole. The client should also be instructed to report any difficulty with breathing and to monitor for changes in stool color. Additionally, the client should avoid consuming grapefruit juice while taking itraconazole.
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