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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Septic shock is a life-threatening condition characterized by a severe infection that leads to systemic inflammation, organ dysfunction, and low blood pressure. Maintaining strict intake and output monitoring is essential to assess the client's fluid balance and response to interventions. It allows the nurse to closely monitor the client's urine output, which is a crucial indicator of renal perfusion and overall organ function.

Monitoring urine output helps the nurse assess the adequacy of tissue perfusion and the client's response to fluid resuscitation. A decrease in urine output can be an early sign of worsening organ dysfunction and a need for further interventions.

While assessing the warmth of extremities is important for evaluating peripheral perfusion, maintaining strict intake and output monitoring takes priority as it provides more comprehensive information about the client's overall fluid status.

Raising the head of the bed 45 degrees (semi-Fowler's position) can help optimize respiratory function and reduce the risk of aspiration, but it is not the most important intervention in this case.

Monitoring blood glucose levels is important, as hyperglycemia can be associated with sepsis. However, in the context of septic shock, maintaining strict intake and output monitoring takes precedence as it directly assesses the client's fluid balance and response to interventions.

It's crucial to note that the management of septic shock requires a multidisciplinary approach, and other interventions, such as administering appropriate antibiotics, initiating fluid resuscitation, and addressing the underlying source of infection, should also be implemented in a timely manner.

A. Review the literature and answer any questions the nurse is able to answer. B. Determine their reasoning for seeking genetic counseling at this time. C. Tell the couple that it is best to call the counselor with their questions. D. Recommend a community support group for parents of children with Trisomy 21.

Correct Answer is A

Explanation

A) Correct- As a nurse, it's important to provide accurate and helpful information to patients and families. In this situation, the parents have brought literature from a genetic counselor and are seeking clarification. The nurse should review the literature to the best of their ability and answer any questions they can. This approach demonstrates support, a willingness to help, and a commitment to providing accurate information.
B) Incorrect- While understanding the parents' reasons for seeking genetic counseling is important, it shouldn't be the first response when they have already brought literature and are seeking clarification. Addressing their questions and concerns is the immediate priority.
C) Incorrect- While it's true that the couple could contact the genetic counselor for further information, as a healthcare professional, the nurse should still offer assistance by reviewing the literature and answering questions to the best of their ability.
D) Incorrect- While support groups can be beneficial for parents of children with Trisomy 21, the immediate concern is addressing the parents' questions about the literature they've brought. Providing accurate information should be the primary focus at this time.

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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)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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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)]