a client with diabetes mellitus reports feeling dizzy and has a blood glucose level of 50 mgdl what action should the nurse take first
Logo

Nursing Elites

HESI RN

HESI RN CAT Exam Quizlet

1. A client with diabetes mellitus reports feeling dizzy and has a blood glucose level of 50 mg/dl. What action should the nurse take first?

Correct answer: B

Rationale: Providing 15 grams of carbohydrate is the initial action to treat hypoglycemia. When a client with diabetes mellitus experiences symptoms of hypoglycemia, such as dizziness and with a blood glucose level of 50 mg/dl, the immediate priority is to raise their blood sugar levels quickly. Administering carbohydrates, such as fruit juice or glucose tablets, is the recommended first step to reverse hypoglycemia. Administering glucagon intramuscularly is usually reserved for severe hypoglycemia when the client is unconscious or unable to swallow. Checking the client's blood pressure is important but not the primary intervention for hypoglycemia. Notifying the healthcare provider can be done after the immediate management of hypoglycemia.

2. A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?

Correct answer: A

Rationale: In a 3-year-old boy presenting with dysphagia, drooling, fever, and stridor, the priority intervention should be to place the child in a mist tent. This intervention helps alleviate respiratory distress, providing immediate relief. Options B, C, and D are not as urgent as ensuring the child's airway is managed effectively. Obtaining a sputum culture, preparing for a tracheostomy, and examining the oropharynx can be done after stabilizing the child's respiratory status.

3. The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?

Correct answer: C

Rationale: The correct answer is C. Partial thromboplastin time (PTT) is the laboratory value that should be monitored to evaluate the effectiveness of heparin therapy. PTT reflects the intrinsic pathway of coagulation and is specifically sensitive to heparin's anticoagulant effects. Monitoring the PTT helps ensure that the client is within the therapeutic range to prevent clot formation without increasing the risk of bleeding. Choices A, B, and D are incorrect because while they are important laboratory values in other contexts, they are not specifically used to monitor the effectiveness of heparin therapy.

4. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 32 breaths/min and a heart rate of 110 beats/min. What action should the nurse take first?

Correct answer: C

Rationale: The correct action for the nurse to take first is to assess the client's oxygen saturation level. In a client with COPD and abnormal respiratory and heart rates, determining the oxygen saturation helps evaluate the adequacy of oxygen exchange and the severity of respiratory distress. Administering a bronchodilator (choice A) can be appropriate but assessing oxygen saturation takes priority. Encouraging deep breathing and coughing (choice B) may not address the immediate need for oxygenation assessment. Obtaining an arterial blood gas (choice D) is important but typically follows the initial assessment of oxygen saturation.

5. The nurse is triaging clients from a train wreck. A client has multiple open wounds, a blood pressure of 90/56, and a pulse of 112 beats/minute. Which triage tag color should the nurse place on this client?

Correct answer: D

Rationale: The correct answer is D: Red. The client's vital signs indicate critical condition with a high pulse and low blood pressure, suggesting shock. A red tag is used to identify patients who require immediate attention and should be prioritized for treatment. Choice A, Black, is incorrect as it is typically used for deceased or expectant clients. Choice B, Yellow, is used for clients with non-life-threatening injuries who require medical care but can wait. Choice C, Green, is for clients with minor injuries who can wait the longest for treatment. Therefore, in this scenario, the client's condition warrants a red triage tag for immediate attention.

Similar Questions

A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?
The healthcare provider is caring for a client with jaundice. Which serum laboratory value is likely to be elevated for this client?
The nurse is caring for a client who is 2 days post-op following an abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?
A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, 'I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home'. What response is best for the nurse to provide?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses