what are the signs of hypoglycemia and how should they be managed

ATI LPN

ATI PN Comprehensive Predictor

1. What are the signs of hypoglycemia, and how should they be managed?

A. Sweating, trembling; administer glucose
B. Headache, confusion; administer insulin
C. Dizziness, fatigue; administer glucose
D. Increased heart rate; provide a high-sugar snack

Correct answer: A

Rationale: The correct signs of hypoglycemia are sweating and trembling. These should be managed by administering glucose to raise blood sugar levels. Headache, confusion, dizziness, fatigue, or increased heart rate are not typical signs of hypoglycemia. Administering insulin in response to hypoglycemia would further lower blood sugar levels, exacerbating the condition.

2. What are the complications of untreated fluid overload?

A. Pulmonary edema and congestive heart failure
B. Hypertension and electrolyte imbalance
C. Liver failure and electrolyte imbalance
D. Pulmonary embolism and dehydration

Correct answer: A

Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.

3. A nurse is planning to irrigate and dress a clean, granulating wound for a client. Which of the following actions should the nurse take?

A. Irrigate the wound with normal saline.
B. Apply a wet-to-dry gauze dressing.
C. Use a cotton ball to cleanse the wound.
D. Administer an analgesic after the dressing change.

Correct answer: A

Rationale: The correct answer is to irrigate the wound with normal saline. Normal saline is the preferred solution for wound irrigation as it is isotonic and gentle, promoting healing in granulating wounds. Choice B, applying a wet-to-dry gauze dressing, is not appropriate for clean, granulating wounds as it can cause trauma to the wound bed upon removal. Choice C, using a cotton ball to cleanse the wound, is not ideal as cotton fibers can adhere to the wound and cause contamination. Choice D, administering an analgesic after the dressing change, is important for pain management but is not directly related to irrigating and dressing the wound.

4. A client with a serum albumin level of 3 g/dL has a pressure ulcer. What should the nurse do first?

A. Monitor the client's fluid and electrolyte balance
B. Consult a dietitian to improve the client's nutritional status
C. Administer a protein supplement
D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: The correct first action for a client with a serum albumin level of 3 g/dL and a pressure ulcer is to consult a dietitian to improve the client's nutritional status. Adequate nutrition is essential for wound healing. Monitoring fluid and electrolyte balance is important but not the first priority in this situation. Administering a protein supplement can be considered after dietary evaluation. Administering an anti-inflammatory medication is not the primary intervention for addressing a pressure ulcer related to low albumin levels.

5. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?

A. The client's urine test is positive for glucose and acetone
B. The client has 1+ pedal edema in both feet at the end of the day
C. The client complains of an increase in vaginal discharge
D. The client says she feels pressure against her diaphragm when the baby moves

Correct answer: A

Rationale: The correct answer is A. Positive urine glucose and acetone could indicate gestational diabetes or preeclampsia, both of which are complications. Choice B, pedal edema, is common in pregnancy but may also be a sign of preeclampsia if severe. Choice C, an increase in vaginal discharge, is a normal finding in pregnancy due to hormonal changes. Choice D, pressure against the diaphragm when the baby moves, is a normal sensation due to the growing uterus displacing abdominal contents.