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 C

Explanation

A) Incorrect- This position is not ideal for managing a nosebleed because it does not promote drainage and may lead to blood flowing down the throat.
B) Incorrect- Leaning the head backward can cause blood to flow down the throat and may lead to choking or aspiration.
C) Correct- Placing the child in a sitting position and leaning forward helps prevent blood from flowing down the back of the throat, which can lead to choking or aspiration. Leaning forward allows the blood to drain out through the nostrils.
D) Incorrect- Placing the child in a supine position with raised legs is not recommended for managing a nosebleed, as it may lead to blood flowing down the throat.

A. Correct dosage of medication B. Vital signs with SaO2 C. Pain report from parent D. Valid pain assessment tool E. Identify allergies F. Subjective pain assessment

Correct Answer is ["A","B","C","D","E"]

Explanation

It is important to assess the child's vital signs, including oxygen saturation (SaO2), to ensure their stability and identify any signs of respiratory distress or other abnormalities that may impact medication administration.

Prior to administering any medication, it is crucial to verify if the child has any known allergies to medications. This information is essential for ensuring the safety of the child and preventing any potential allergic reactions.

Before administering pain medication, the nurse must verify that the prescribed dosage is appropriate for the child's age, weight, and condition. Ensuring the correct dosage helps prevent medication errors and potential adverse effects.

It is important to use a validated pain assessment tool that is appropriate for the child's age and cognitive abilities. This allows for a comprehensive and accurate assessment of the child's pain level, helping guide appropriate pain management interventions.

Considering the child has cognitive and speech delays, the input from the parent regarding the child's pain is valuable. The nurse should assess and consider the parent's report of the child's pain in conjunction with other assessment findings to ensure effective pain management.

Subjective pain assessment is mentioned as a finding but may not require immediate action, as it needs to be combined with other assessment data for a comprehensive evaluation.

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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)]

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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)]