Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Clubbing of the fingernails

Tracheal deviation

Contraction of the diaphragm

Auscultation of rhonchi throughout the lungs

Answer and Explanation

The Correct Answer is B

A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.

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Correct Answer is A

Explanation

A. After administering a carbohydrate source (e.g., 6 oz of orange juice), the nurse should reassess the patient's blood glucose level. If the glucose is still below the target range (typically above 70 mg/dL), the next step is to give an additional 15 grams of carbohydrate to raise the blood sugar. This is a standard approach for mild to moderate hypoglycemia.
B. Giving 25 to 50 ml of 50% glucose IV is typically reserved for patients who are severely hypoglycemic and unable to swallow or are unresponsive. This method is appropriate when the patient cannot take oral glucose, but the client in this scenario is still conscious.
C. Administering 1 mg IM glucagon is used when a patient is unable to ingest glucose orally and is unresponsive or vomiting. It stimulates the liver to release stored glucose, but this is not necessary in a conscious patient who can swallow.
D. Administering a 5% to 10% dextrose infusion is typically used in more severe cases of hypoglycemia, especially when IV access is established, and the patient is unable to take oral glucose. This would not be necessary for a patient who can safely swallow.

A. Polyuria B. Tachycardia C. Blurred vision D. Polydipsia E. Moist, clammy skin

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

Explanation

A. Polyuria is typically a symptom of hyperglycemia (high blood sugar) rather than hypoglycemia. When blood glucose is elevated, the kidneys attempt to excrete the excess glucose, leading to increased urination.
B. Tachycardia (increased heart rate) is a common sign of hypoglycemia due to the body's stress response to low blood sugar. The release of adrenaline (epinephrine) can cause a rapid heart rate.
C. Blurred vision can occur with hypoglycemia because low glucose levels can affect the function of the retina and cause vision changes. This can resolve once the blood glucose level is normalized.
D. Polydipsia (excessive thirst) is more commonly seen in hyperglycemia, as high blood glucose leads to dehydration due to increased urination.
E. Moist, clammy skin is a classic sign of hypoglycemia. When blood sugar drops too low, the body activates the sympathetic nervous system, which can cause sweating and clammy skin.

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Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

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Naxlex Comprehensive Predictor Exams

After giving 6 oz of orange juice to a patient with hypoglycemia, the nurse finds that the patient's blood glucose level is 65 mg/dl. Which nursing intervention would be the most appropriate in this situation?

Correct Answer is A

Explanation

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)

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

Explanation

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